HEALTH SERVICE APPLICATION
Creating a School-Based Eye Care Program HANS D. SCHMALZRIED, PhDa BARBARA GUNNING, PhD BSNb TODD PLATZER, MPHc
Keywords: health service applications; school-based clinics; school health services. Citation: Schmalzried HD, Gunning B, Platzer T. Creating a school-based eye care program. J Sch Health. 2015; 85: 341-345. Received on January 17, 2014 Accepted on October 1, 2014
V
ision impairment is one of the most disabling conditions facing children today, according to The Centers for Disease Control and Prevention. Vision impairment negatively affects neurological, cognitive, and emotional development by limiting children’s exposure to a range of experiences and information.1 Between 70% and 80% of what a child learns is visually acquired.2 This places children with vision problems at a tremendous disadvantage before they enter the classroom.2,3 It is estimated that 25% of all students in the United States have undiagnosed vision problems significant enough to affect their performance in school and in life.4,5 This represents approximately 18 million children, with the rates increasing as age of children increases.4,6 Despite this large number, less than one-third of the affected children have their vision screened before the age of 6.7 Of these, only about half of preschool-aged children receive comprehensive eye examinations before entering first grade.7,8 Vision problems affect a disproportionately higher number of urban and minority youth.9 For children living in poverty, the percentage of those with undiagnosed vision problems is close to 50%, with many of these children coming from minority populations.3 A pressing need in education is to close achievement gaps in academic performance among these populations.10 Assuring that children receive professional eye examinations and remedial treatment could improve their academic performance and help close achievement gaps. According to the American Academy of Ophthalmology, every student should have a professional eye examination, which includes a test of visual acuity, by the age of 5 years.11,12 Ideally, this should
be repeated every 2 years thereafter.13 Unfortunately, lack of resources limits the availability of professional vision examinations to children. For most children in the United States, a school-based vision screening is the only vision service they will receive.14 Screenings are not diagnostic, but are intended only to identify potential problems.12 Without follow-up care, screenings are of little value.13 Students who live in urban areas appear to have more problems receiving follow-up eye care services after not passing a school-based vision screening. A study of a school district serving nearly 21,000 students in the Baltimore City School system found that only 17% of students who did not pass vision screening received follow-up care.15 Children who resided in urban areas were more susceptible to poverty, malnutrition, and poor vision than their peers in higher socioeconomic areas.16,17 In a study conducted in a Connecticut school district, researchers found that 29% of students who failed vision screenings did not receive follow-up eye care owing to parental unawareness of the results.18 Miscommunication and lack of clarity in screening results were the most prominent barriers for receiving follow-up. Another barrier identified was timeliness. When the follow-up care was not administered within 2 months of the screening, it was less likely the child would receive care.18 Other barriers identified in a study conducted by Kimel19 included financial (cost and money concerns, no insurance coverage), social and family issues (difficulty getting appointments because of work schedules, parents with mental or physical disabilities), logistical problems (trouble scheduling appointments,
a Professor Emeritus, ([email protected]), Department of Public and Allied Health Bowling Green State University, 100 Health Center Ridge Street, Bowling Green, OH 43403. bDirector of Health Services, ([email protected]), Toledo-Lucas County Health Department, 635 N. Erie Street, Toledo, OH 43604. c Graduate Assistant, Department of Public and Allied Health, ([email protected]), Bowling Green State University, 100 Health Center Ridge Street, Bowling Green, OH 43403.
Address correspondence to: Hans D. Schmalzried, ([email protected]), Bowling Green State University, Public and Allied Health, 100 Health Center Ridge Road, Bowling Green, OH 43403.
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difficulty planning ahead), and perceptual barriers (vision problem not given a priority, mistrust of school nurse). Last, many parents may have the wrong perception that vision screening conducted by a school nurse is the replacement for comprehensive eye examinations by professionals.12
RATIONALE FOR ESTABLISHING A SCHOOL-BASED EYE CARE CLINIC IN LUCAS COUNTY, OHIO The 2012 population of the city of Toledo located in Lucas County, Ohio, was 284,012, with almost 65% of residents identifying themselves as white.20 A total of 22,300 children were estimated to attend school in the Toledo Public School District during the 2011-2012 and 2012-2013 school years.21 During 2007-2011, the average number of persons in Toledo living below the federal poverty level was 25.6%.20 For many years, Toledo Public Schools operated a vision-screening program where school nurses screened students for vision in kindergarten, third, fifth, seventh and ninth grades. When a child did not pass a screening, a note was sent home to the parent or the caregiver. The note advised parents or caregivers that the child needed a professional eye examination. This process was not effective toward facilitating follow-up to failed screenings, and hundreds of children were likely left struggling to see clearly. One Toledo Public Schools’ principal observed that many students struggled to see the chalkboard and appeared to need vision care, including eyeglasses. The principal raised his concerns to a local nonprofit social agency, the United Way of Greater Toledo. A task force was formed, with the major goal to improve access to eye care by bringing professionals directly to the schools. The principal championed what became a community effort to extend vision care services to children throughout the Toledo Public Schools District.
PILOT-TESTING A SCHOOL-BASED EYE CARE CLINIC A 2-day pilot vision clinic was implemented with funding from the United Way of Greater Toledo. The pilot vision clinic was a short-term plan to make vision services accessible to children in Toledo. The clinic was established with a partnership between the Ohio Optometric Association, Toledo Optical (a local optometry business), and volunteer optometrists. Vision testing equipment was leased. Optometrists provided eye examinations and glasses. Students received a comprehensive eye examination and selected frames for their glasses on-site. Toledo Optical processed the lenses and returned the finished glasses to the students the following week. During the 2-day pilot vision clinic, eye examinations were provided to 43 students previously screened 342
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and needed follow-up. Forty-one needed glasses. Two students were diagnosed with glaucoma, and 2 were diagnosed with cataracts. Most students reported that this was their first examination or that their glasses had broken and they could not afford another pair. The pilot vision clinic provided clear evidence of the need for children from low-income families in the Toledo Public School District to have easy access to treatment for vision problems. Findings from the pilot vision clinic corroborated what was found in the literature review; vision problems are pervasive among urban youth. Although the pilot vision clinic provided a shortterm solution for vision care, it was recognized that more planning and resources would be needed to serve multiple schools and thousands of children on a long-term basis. A workgroup was formed in 2010 with members from organizations that included Toledo Public Schools, The Sight Center of Northwest Ohio, Prevent Blindness Ohio, private optometrists, United Way of Greater Toledo, and the Toledo-Lucas County Health Department. Their work led to the formation of a school-based vision program, The Toledo Public Schools Eye Care Program.
THE TOLEDO SCHOOL-BASED EYE CARE PROGRAM The workgroup proceeded to plan and develop operational and equipment budgets. The United Way of Greater Toledo provided a $103,000 grant for operations. A second grant award for $25,000 was secured from a local bank and used for the startup budget to purchase ophthalmic equipment and supplies. The start-up budget for equipment and supplies amounted to $24,613 (Table 1). Expenses from the first year of operation were almost $90,000; this included the one-time expense of purchasing start-up equipment. The cost per student serviced through the program averaged $131, which included the cost of the examination and the glasses. Medicaid reimbursement for each student averaged $36. Most of the student participants are covered under Medicaid. A local nonprofit agency, Prevent Blindness, committed to provide glasses for income-eligible children not enrolled in Medicaid or covered by other health insurance plans. The Toledo-Lucas County Health Department was selected to administer the project. The program was modeled after a dental clinic serving 53 schools operated by the Health Department. Staff administering the dental clinic assisted with planning of the Eye Care Program. Student participants are identified through traditional vision screenings provided at the schools. Children requiring professional follow-up are provided parental consent slips to take home. By returning these © 2015, American School Health Association
Table 1. Start-Up Equipment Budget 2011 Budget Item
Cost
Computerized tonometer Slit lamp Refractor with minus cylinders Digital acuity system Binocular indirect ophthalmoscope Instrument table Full diameter trial lens set Pupilometer Battery pack with transformer Retinoscope Opthalmoscope Universal trial frame Two-well handles ($124 each) Aspheric lens Stereo Randot test Table mount Double instrument table top Ishihara 14 plate book test Slide Projector bulb Total
$6895 $4295 $3995 $2895 $1888 $845 $695 $539 $519 $372 $275 $269 $248 $227 $160 $145 $125 $125 $69 $32 $24,613
Source: Toledo Lucas County Health Department.
slips, students become enrolled in the School-based Eye Care Program. Students may also be identified and enrolled upon the request of their parent(s) or through referral by their teacher. The project director coordinates clinic schedules with the schools. Operating the vision clinic involves transporting ophthalmic equipment from one school to the other. A van owned by the Health Department is used to transport equipment and personnel. A licensed optometrist completes an eye examination, prescribes corrective lenses, and recommends a referral as necessary. An optician fits children who require eyeglasses. A wide collection of frames is available for the students to choose from. The Health Department purchases the glasses for the children and bills Medicaid for the cost. Low-income children not covered by Medicaid or other health insurance receive a voucher for eyeglasses from Prevent Blindness Ohio. The optician assists the optometrist with examinations, sets up the mobile unit, and occasionally conducts classroom presentations on eye care and safety. All billing information is submitted to a clerk. The clerk processes the billing and assists parents with completing and submitting Healthy Start applications in cases when a child is not enrolled in Medicaid or private insurance. The School-based Eye Care Program began operations in August 2011. In 2013, 42 schools were served. The clinic operates Monday through Friday during the academic school year. Program staff includes a licensed optometrist, certified optician, program coordinator, and clerk. The Program adheres to requirements of Journal of School Health
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professional eye care practice. The School-based Eye Care Program targets children enrolled in kindergarten, third, and fifth grades. The Program ensures that it is reaching its target population by focusing on schools with high participation rate in the free and reduced-cost meal program.
ADDRESSING BARRIERS The Toledo Public School-based Eye Care Program minimizes barriers to access for low-income children. This is primarily accomplished by bringing the clinic directly to the schools. Low parental consent form return rates have prevented some students from receiving services. Only 3 of 8 (37.5%) children needing follow-up returned signed consent forms. Students who do not return forms do not receive follow-up vision care. A strategy to increase the return rates of consent forms is being tested by giving classroom teachers incentives such as gift cards. Further study needs to be conducted to identify the factors that prevent parents from returning consent forms. There appears to be a perception that school vision screenings are comprehensive eye care programs. To address the misperception, consent forms should include information to encourage parents to seek professional eye services for their children. Consideration should also be given to implement the use of a comprehensive medical consent form that would allow approval for various treatments including dental, medical, and vision. Broken and lost glasses have been a concern for program administrators. To address this issue, parents are now provided with a contact phone number to call when glasses are lost or broken. One replacement pair of glasses is also provided for every 12-month period to students who either lose or break their glasses. Last year, 93 (17%) students who participated in the Eye Care Program reported that they lost or broke their glasses and then had them replaced.
PROGRAM EVALUATION One measure of the program’s success has been that many children received vision services who otherwise would have not. During year 1 of the program, eye examinations were provided to 499 students, of whom 376 needed glasses. Referrals were made for 50 vision conditions requiring additional treatment (Table 2). During year 2 of the program, eye examinations were provided to 635 students, of whom 548 needed glasses. Referrals were made for 49 vision conditions requiring additional treatment (Table 2). This year the program is on track to provide even higher numbers of examinations and treatments.
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Table 2. Clinic Summary Data 2011-2012 Vision Condition Needed glasses Suspected glaucoma Amblyopia Astigmatism Cataract Corneal scar No clinical diagnosis
2012-2013
Number Number (n = 499) Percentage (n = 635) Percentage 376 7 21 19 2 1 73
75.4 1.4 4.2 3.8 0.4 0.2 14.6
548 3 37 9 0 0 38
86.3 4.7 5.8 1.4 0.0 0.0 5.9
Source: Toledo Lucas County Health Department.
REFERENCES
Program administrators are preparing to implement a system to evaluate the effectiveness of the School-based Eye Care Program as it relates to academic performance. Program administrators will use SuccessMaker®, a computerized student performance evaluation system to gauge academic advancement. (SuccessMaker® is available through Pearson Digital Learning located at 330 Hudson Street, New York, NY 10013 USA.) All Toledo Public School students use SuccessMaker®. The plan is to use SuccessMaker® academic performance data and correlate them with the treatment of vision problems. Academic performance measures will be compared at 6-, 9-, and 12-month intervals, commencing from the time when an intervention (eg, student received glasses) occurred. A control group will be used to help rule out alternate variables. Whereas this more objective evaluation of the program is not slated for implementation until the next academic year, improvement in academics has been documented subjectively through conversations with teachers and parents. These conversations indicated that students’ reading and academic performance had improved. This Toledo Public School-based Eye Care Program serves children in an urban setting where minorities make up more than 35% of the population. It is not known whether children from low-income families in rural areas experience the same levels of vision problems as the urban poor. This issue may warrant further investigation.
PROGRAM SUSTAINABILITY The financial goal of the School-based Eye Care Program is to break even. Diligent billing of Medicaid and other health insurers will help to ensure the program’s viability. Program administrators may want to explore partnering with Federally Qualified Health Centers (FQHCs) for services; these facilities qualify for enhanced Medicaid reimbursement. Higher rates of reimbursement could then be obtained for services provided through the program. Community resources such as the Sight Center of Northwest Ohio and 344
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Prevent Blindness Ohio will continue to be used whenever a child meets the organization’s eligibility criteria. Supplemental funding was needed to support this program in its first 3 years. In the meantime, the United Way of Greater Toledo has shown a commitment to continue financial support. The School-based Eye Care Program satisfies this organization’s objectives by creating a positive impact on children’s well-being in the community.
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1. Centers for Disease Control and Prevention (CDC). Fast facts. Available at: http://www.cdc.gov/visionhealth/basic_ information/index.htm. Accessed April 10, 2014. 2. Ottar WL, Scott WE, Holgado SI. Photoscreening for amblyogenic factors. J Pediatr Ophthalmol Strabismus. 1995;32(5):289295. 3. Gould MC, Gould H. A clear vision for equity and opportunity. Phi Delta Kappan. 2003;85(4):324-328. 4. American Optometric Association. The need for comprehensive vision examination of preschool and school-age children. Available at: http://www.aoa.org/optometrists/education-andtraining/clinical-care/the-need-for-comprehensive-visionexamination-of-preschool-and-school-age-children. Accessed January 4, 2014. 5. Roberts J. Eye examination findings among youths ages 12-17 years, United States. Vital Health Statistics, Series 11, No. 155, DHEW Publication (HRA): Rockville, Md. 1975;76-1637. 6. Federal Interagency Forum on Child and Family Statistics. America’s Children: Key National Indicators of Wellbeing 2013. Washington, DC: US Government Printing Office. Available at: http://childstats.gov/pdf/ac2013/ac_13.pdf. Accessed January 14, 2014. 7. Prevent Blindness America. Our Vision or Children’s Vision 2008. Available at: http://www.prevent blindness.net/site/DocServer/08-045_OVFCV_small.pdf?docID =1601. Accessed December 10, 2013. 8. Centers for Disease Control and Prevention. Healthy Vision: Making It Last a Lifetime. Available at: http://www. cdc.gov/Features/Healthy Vision/. Accessed August 2, 2014. 9. Basch CE. Vision and the achievement gap among urban minority youth. J Sch Health. 2011;81(10):599-605. 10. Bromberg M, Theokas C. Breaking the glass ceiling of achievement for low-income students and students of color. The Education Trust, Washington, DC. Shattering Expectation Series, Published May 2013. Available at: http://www. edtrust.org/sites/edtrust.org/files/Glass_Ceiling_0.pdf. Accessed January 10, 2014. 11. The Ophthalmic News & Education Network. Vision Screening for Infants and Children, November 2013. Available at: http://one.aao.org/clinical-statement/vision-screeninginfants-children-2013. Accessed December 12, 2013. 12. Chou R, Dana T, Bougatsos C. Screening for visual impairment in children ages 1-5 years: update for the USPSTF. Pediatrics. 2011;127(2):442-479. 13. American Optometric Association. Limitations of Vision Screening Programs, January 2014. Available at: http://www. aoa.org/patients-and-public/caring-for-your-vision/comprehensive-eye-and-vision-examination/limitations-of-visionscreening-programs. Accessed January 15, 2014. 14. Beauchamp GR, Ellepola C, Beauchamp CL. Evidence-based medicine: the value of vision screening. Am Orthopt J. 2010;60(1):23-27.
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15. The Abell Foundation Report September 2010. Why can’t Johnny read? Available at: http://www.abell.org/pubsitems/arn 910jn.pdf. Accessed December 15, 2013. 16. Unite for Sight. Challenges and Failures of Vision Screenings. Available at: http://www.uniteforsight.org/healthscreenings/vision-screenings. Accessed January 4, 2014. 17. Bodack M, Chung I, Krumholtz I. An analysis of vision screening data from New York City public schools. Optometry. 2010;81(9):476-484. 18. Su Z, Marvin EK, Wang BQ, et al. Identifying barriers to followup eye care for children after failed vision screening in a primary care setting. J AAPOS. 2013;17(4):385-390.
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19. Kimel LS. Lack of follow-up exams after failed school vision screenings: an investigation of contributing factors. J Sch Nurs. 2006;22(3):156-162. 20. United States Census Bureau. State and County Quickfacts. Available at: http://quickfacts.census.gov/qfd/states/ 39/3977000.html. Accessed August 2, 2014. 21. Toledo Public Schools. Report of the Performance Audit for Toledo Public Schools. Available at: http://www.tps.org/images/ stories/district_programs/Treasurer/revised%20version%20tps %20audit%20report%20june%204%202013.pdf. Accessed January 4, 2014.
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Creating a School-Based Eye Care Program HANS D. SCHMALZRIED, PhDa BARBARA GUNNING, PhD BSNb TODD PLATZER, MPHc
Keywords: health service applications; school-based clinics; school health services. Citation: Schmalzried HD, Gunning B, Platzer T. Creating a school-based eye care program. J Sch Health. 2015; 85: 341-345. Received on January 17, 2014 Accepted on October 1, 2014
V
ision impairment is one of the most disabling conditions facing children today, according to The Centers for Disease Control and Prevention. Vision impairment negatively affects neurological, cognitive, and emotional development by limiting children’s exposure to a range of experiences and information.1 Between 70% and 80% of what a child learns is visually acquired.2 This places children with vision problems at a tremendous disadvantage before they enter the classroom.2,3 It is estimated that 25% of all students in the United States have undiagnosed vision problems significant enough to affect their performance in school and in life.4,5 This represents approximately 18 million children, with the rates increasing as age of children increases.4,6 Despite this large number, less than one-third of the affected children have their vision screened before the age of 6.7 Of these, only about half of preschool-aged children receive comprehensive eye examinations before entering first grade.7,8 Vision problems affect a disproportionately higher number of urban and minority youth.9 For children living in poverty, the percentage of those with undiagnosed vision problems is close to 50%, with many of these children coming from minority populations.3 A pressing need in education is to close achievement gaps in academic performance among these populations.10 Assuring that children receive professional eye examinations and remedial treatment could improve their academic performance and help close achievement gaps. According to the American Academy of Ophthalmology, every student should have a professional eye examination, which includes a test of visual acuity, by the age of 5 years.11,12 Ideally, this should
be repeated every 2 years thereafter.13 Unfortunately, lack of resources limits the availability of professional vision examinations to children. For most children in the United States, a school-based vision screening is the only vision service they will receive.14 Screenings are not diagnostic, but are intended only to identify potential problems.12 Without follow-up care, screenings are of little value.13 Students who live in urban areas appear to have more problems receiving follow-up eye care services after not passing a school-based vision screening. A study of a school district serving nearly 21,000 students in the Baltimore City School system found that only 17% of students who did not pass vision screening received follow-up care.15 Children who resided in urban areas were more susceptible to poverty, malnutrition, and poor vision than their peers in higher socioeconomic areas.16,17 In a study conducted in a Connecticut school district, researchers found that 29% of students who failed vision screenings did not receive follow-up eye care owing to parental unawareness of the results.18 Miscommunication and lack of clarity in screening results were the most prominent barriers for receiving follow-up. Another barrier identified was timeliness. When the follow-up care was not administered within 2 months of the screening, it was less likely the child would receive care.18 Other barriers identified in a study conducted by Kimel19 included financial (cost and money concerns, no insurance coverage), social and family issues (difficulty getting appointments because of work schedules, parents with mental or physical disabilities), logistical problems (trouble scheduling appointments,
a Professor Emeritus, ([email protected]), Department of Public and Allied Health Bowling Green State University, 100 Health Center Ridge Street, Bowling Green, OH 43403. bDirector of Health Services, ([email protected]), Toledo-Lucas County Health Department, 635 N. Erie Street, Toledo, OH 43604. c Graduate Assistant, Department of Public and Allied Health, ([email protected]), Bowling Green State University, 100 Health Center Ridge Street, Bowling Green, OH 43403.
Address correspondence to: Hans D. Schmalzried, ([email protected]), Bowling Green State University, Public and Allied Health, 100 Health Center Ridge Road, Bowling Green, OH 43403.
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difficulty planning ahead), and perceptual barriers (vision problem not given a priority, mistrust of school nurse). Last, many parents may have the wrong perception that vision screening conducted by a school nurse is the replacement for comprehensive eye examinations by professionals.12
RATIONALE FOR ESTABLISHING A SCHOOL-BASED EYE CARE CLINIC IN LUCAS COUNTY, OHIO The 2012 population of the city of Toledo located in Lucas County, Ohio, was 284,012, with almost 65% of residents identifying themselves as white.20 A total of 22,300 children were estimated to attend school in the Toledo Public School District during the 2011-2012 and 2012-2013 school years.21 During 2007-2011, the average number of persons in Toledo living below the federal poverty level was 25.6%.20 For many years, Toledo Public Schools operated a vision-screening program where school nurses screened students for vision in kindergarten, third, fifth, seventh and ninth grades. When a child did not pass a screening, a note was sent home to the parent or the caregiver. The note advised parents or caregivers that the child needed a professional eye examination. This process was not effective toward facilitating follow-up to failed screenings, and hundreds of children were likely left struggling to see clearly. One Toledo Public Schools’ principal observed that many students struggled to see the chalkboard and appeared to need vision care, including eyeglasses. The principal raised his concerns to a local nonprofit social agency, the United Way of Greater Toledo. A task force was formed, with the major goal to improve access to eye care by bringing professionals directly to the schools. The principal championed what became a community effort to extend vision care services to children throughout the Toledo Public Schools District.
PILOT-TESTING A SCHOOL-BASED EYE CARE CLINIC A 2-day pilot vision clinic was implemented with funding from the United Way of Greater Toledo. The pilot vision clinic was a short-term plan to make vision services accessible to children in Toledo. The clinic was established with a partnership between the Ohio Optometric Association, Toledo Optical (a local optometry business), and volunteer optometrists. Vision testing equipment was leased. Optometrists provided eye examinations and glasses. Students received a comprehensive eye examination and selected frames for their glasses on-site. Toledo Optical processed the lenses and returned the finished glasses to the students the following week. During the 2-day pilot vision clinic, eye examinations were provided to 43 students previously screened 342
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and needed follow-up. Forty-one needed glasses. Two students were diagnosed with glaucoma, and 2 were diagnosed with cataracts. Most students reported that this was their first examination or that their glasses had broken and they could not afford another pair. The pilot vision clinic provided clear evidence of the need for children from low-income families in the Toledo Public School District to have easy access to treatment for vision problems. Findings from the pilot vision clinic corroborated what was found in the literature review; vision problems are pervasive among urban youth. Although the pilot vision clinic provided a shortterm solution for vision care, it was recognized that more planning and resources would be needed to serve multiple schools and thousands of children on a long-term basis. A workgroup was formed in 2010 with members from organizations that included Toledo Public Schools, The Sight Center of Northwest Ohio, Prevent Blindness Ohio, private optometrists, United Way of Greater Toledo, and the Toledo-Lucas County Health Department. Their work led to the formation of a school-based vision program, The Toledo Public Schools Eye Care Program.
THE TOLEDO SCHOOL-BASED EYE CARE PROGRAM The workgroup proceeded to plan and develop operational and equipment budgets. The United Way of Greater Toledo provided a $103,000 grant for operations. A second grant award for $25,000 was secured from a local bank and used for the startup budget to purchase ophthalmic equipment and supplies. The start-up budget for equipment and supplies amounted to $24,613 (Table 1). Expenses from the first year of operation were almost $90,000; this included the one-time expense of purchasing start-up equipment. The cost per student serviced through the program averaged $131, which included the cost of the examination and the glasses. Medicaid reimbursement for each student averaged $36. Most of the student participants are covered under Medicaid. A local nonprofit agency, Prevent Blindness, committed to provide glasses for income-eligible children not enrolled in Medicaid or covered by other health insurance plans. The Toledo-Lucas County Health Department was selected to administer the project. The program was modeled after a dental clinic serving 53 schools operated by the Health Department. Staff administering the dental clinic assisted with planning of the Eye Care Program. Student participants are identified through traditional vision screenings provided at the schools. Children requiring professional follow-up are provided parental consent slips to take home. By returning these © 2015, American School Health Association
Table 1. Start-Up Equipment Budget 2011 Budget Item
Cost
Computerized tonometer Slit lamp Refractor with minus cylinders Digital acuity system Binocular indirect ophthalmoscope Instrument table Full diameter trial lens set Pupilometer Battery pack with transformer Retinoscope Opthalmoscope Universal trial frame Two-well handles ($124 each) Aspheric lens Stereo Randot test Table mount Double instrument table top Ishihara 14 plate book test Slide Projector bulb Total
$6895 $4295 $3995 $2895 $1888 $845 $695 $539 $519 $372 $275 $269 $248 $227 $160 $145 $125 $125 $69 $32 $24,613
Source: Toledo Lucas County Health Department.
slips, students become enrolled in the School-based Eye Care Program. Students may also be identified and enrolled upon the request of their parent(s) or through referral by their teacher. The project director coordinates clinic schedules with the schools. Operating the vision clinic involves transporting ophthalmic equipment from one school to the other. A van owned by the Health Department is used to transport equipment and personnel. A licensed optometrist completes an eye examination, prescribes corrective lenses, and recommends a referral as necessary. An optician fits children who require eyeglasses. A wide collection of frames is available for the students to choose from. The Health Department purchases the glasses for the children and bills Medicaid for the cost. Low-income children not covered by Medicaid or other health insurance receive a voucher for eyeglasses from Prevent Blindness Ohio. The optician assists the optometrist with examinations, sets up the mobile unit, and occasionally conducts classroom presentations on eye care and safety. All billing information is submitted to a clerk. The clerk processes the billing and assists parents with completing and submitting Healthy Start applications in cases when a child is not enrolled in Medicaid or private insurance. The School-based Eye Care Program began operations in August 2011. In 2013, 42 schools were served. The clinic operates Monday through Friday during the academic school year. Program staff includes a licensed optometrist, certified optician, program coordinator, and clerk. The Program adheres to requirements of Journal of School Health
•
professional eye care practice. The School-based Eye Care Program targets children enrolled in kindergarten, third, and fifth grades. The Program ensures that it is reaching its target population by focusing on schools with high participation rate in the free and reduced-cost meal program.
ADDRESSING BARRIERS The Toledo Public School-based Eye Care Program minimizes barriers to access for low-income children. This is primarily accomplished by bringing the clinic directly to the schools. Low parental consent form return rates have prevented some students from receiving services. Only 3 of 8 (37.5%) children needing follow-up returned signed consent forms. Students who do not return forms do not receive follow-up vision care. A strategy to increase the return rates of consent forms is being tested by giving classroom teachers incentives such as gift cards. Further study needs to be conducted to identify the factors that prevent parents from returning consent forms. There appears to be a perception that school vision screenings are comprehensive eye care programs. To address the misperception, consent forms should include information to encourage parents to seek professional eye services for their children. Consideration should also be given to implement the use of a comprehensive medical consent form that would allow approval for various treatments including dental, medical, and vision. Broken and lost glasses have been a concern for program administrators. To address this issue, parents are now provided with a contact phone number to call when glasses are lost or broken. One replacement pair of glasses is also provided for every 12-month period to students who either lose or break their glasses. Last year, 93 (17%) students who participated in the Eye Care Program reported that they lost or broke their glasses and then had them replaced.
PROGRAM EVALUATION One measure of the program’s success has been that many children received vision services who otherwise would have not. During year 1 of the program, eye examinations were provided to 499 students, of whom 376 needed glasses. Referrals were made for 50 vision conditions requiring additional treatment (Table 2). During year 2 of the program, eye examinations were provided to 635 students, of whom 548 needed glasses. Referrals were made for 49 vision conditions requiring additional treatment (Table 2). This year the program is on track to provide even higher numbers of examinations and treatments.
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Table 2. Clinic Summary Data 2011-2012 Vision Condition Needed glasses Suspected glaucoma Amblyopia Astigmatism Cataract Corneal scar No clinical diagnosis
2012-2013
Number Number (n = 499) Percentage (n = 635) Percentage 376 7 21 19 2 1 73
75.4 1.4 4.2 3.8 0.4 0.2 14.6
548 3 37 9 0 0 38
86.3 4.7 5.8 1.4 0.0 0.0 5.9
Source: Toledo Lucas County Health Department.
REFERENCES
Program administrators are preparing to implement a system to evaluate the effectiveness of the School-based Eye Care Program as it relates to academic performance. Program administrators will use SuccessMaker®, a computerized student performance evaluation system to gauge academic advancement. (SuccessMaker® is available through Pearson Digital Learning located at 330 Hudson Street, New York, NY 10013 USA.) All Toledo Public School students use SuccessMaker®. The plan is to use SuccessMaker® academic performance data and correlate them with the treatment of vision problems. Academic performance measures will be compared at 6-, 9-, and 12-month intervals, commencing from the time when an intervention (eg, student received glasses) occurred. A control group will be used to help rule out alternate variables. Whereas this more objective evaluation of the program is not slated for implementation until the next academic year, improvement in academics has been documented subjectively through conversations with teachers and parents. These conversations indicated that students’ reading and academic performance had improved. This Toledo Public School-based Eye Care Program serves children in an urban setting where minorities make up more than 35% of the population. It is not known whether children from low-income families in rural areas experience the same levels of vision problems as the urban poor. This issue may warrant further investigation.
PROGRAM SUSTAINABILITY The financial goal of the School-based Eye Care Program is to break even. Diligent billing of Medicaid and other health insurers will help to ensure the program’s viability. Program administrators may want to explore partnering with Federally Qualified Health Centers (FQHCs) for services; these facilities qualify for enhanced Medicaid reimbursement. Higher rates of reimbursement could then be obtained for services provided through the program. Community resources such as the Sight Center of Northwest Ohio and 344
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Prevent Blindness Ohio will continue to be used whenever a child meets the organization’s eligibility criteria. Supplemental funding was needed to support this program in its first 3 years. In the meantime, the United Way of Greater Toledo has shown a commitment to continue financial support. The School-based Eye Care Program satisfies this organization’s objectives by creating a positive impact on children’s well-being in the community.
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1. Centers for Disease Control and Prevention (CDC). Fast facts. Available at: http://www.cdc.gov/visionhealth/basic_ information/index.htm. Accessed April 10, 2014. 2. Ottar WL, Scott WE, Holgado SI. Photoscreening for amblyogenic factors. J Pediatr Ophthalmol Strabismus. 1995;32(5):289295. 3. Gould MC, Gould H. A clear vision for equity and opportunity. Phi Delta Kappan. 2003;85(4):324-328. 4. American Optometric Association. The need for comprehensive vision examination of preschool and school-age children. Available at: http://www.aoa.org/optometrists/education-andtraining/clinical-care/the-need-for-comprehensive-visionexamination-of-preschool-and-school-age-children. Accessed January 4, 2014. 5. Roberts J. Eye examination findings among youths ages 12-17 years, United States. Vital Health Statistics, Series 11, No. 155, DHEW Publication (HRA): Rockville, Md. 1975;76-1637. 6. Federal Interagency Forum on Child and Family Statistics. America’s Children: Key National Indicators of Wellbeing 2013. Washington, DC: US Government Printing Office. Available at: http://childstats.gov/pdf/ac2013/ac_13.pdf. Accessed January 14, 2014. 7. Prevent Blindness America. Our Vision or Children’s Vision 2008. Available at: http://www.prevent blindness.net/site/DocServer/08-045_OVFCV_small.pdf?docID =1601. Accessed December 10, 2013. 8. Centers for Disease Control and Prevention. Healthy Vision: Making It Last a Lifetime. Available at: http://www. cdc.gov/Features/Healthy Vision/. Accessed August 2, 2014. 9. Basch CE. Vision and the achievement gap among urban minority youth. J Sch Health. 2011;81(10):599-605. 10. Bromberg M, Theokas C. Breaking the glass ceiling of achievement for low-income students and students of color. The Education Trust, Washington, DC. Shattering Expectation Series, Published May 2013. Available at: http://www. edtrust.org/sites/edtrust.org/files/Glass_Ceiling_0.pdf. Accessed January 10, 2014. 11. The Ophthalmic News & Education Network. Vision Screening for Infants and Children, November 2013. Available at: http://one.aao.org/clinical-statement/vision-screeninginfants-children-2013. Accessed December 12, 2013. 12. Chou R, Dana T, Bougatsos C. Screening for visual impairment in children ages 1-5 years: update for the USPSTF. Pediatrics. 2011;127(2):442-479. 13. American Optometric Association. Limitations of Vision Screening Programs, January 2014. Available at: http://www. aoa.org/patients-and-public/caring-for-your-vision/comprehensive-eye-and-vision-examination/limitations-of-visionscreening-programs. Accessed January 15, 2014. 14. Beauchamp GR, Ellepola C, Beauchamp CL. Evidence-based medicine: the value of vision screening. Am Orthopt J. 2010;60(1):23-27.
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15. The Abell Foundation Report September 2010. Why can’t Johnny read? Available at: http://www.abell.org/pubsitems/arn 910jn.pdf. Accessed December 15, 2013. 16. Unite for Sight. Challenges and Failures of Vision Screenings. Available at: http://www.uniteforsight.org/healthscreenings/vision-screenings. Accessed January 4, 2014. 17. Bodack M, Chung I, Krumholtz I. An analysis of vision screening data from New York City public schools. Optometry. 2010;81(9):476-484. 18. Su Z, Marvin EK, Wang BQ, et al. Identifying barriers to followup eye care for children after failed vision screening in a primary care setting. J AAPOS. 2013;17(4):385-390.
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19. Kimel LS. Lack of follow-up exams after failed school vision screenings: an investigation of contributing factors. J Sch Nurs. 2006;22(3):156-162. 20. United States Census Bureau. State and County Quickfacts. Available at: http://quickfacts.census.gov/qfd/states/ 39/3977000.html. Accessed August 2, 2014. 21. Toledo Public Schools. Report of the Performance Audit for Toledo Public Schools. Available at: http://www.tps.org/images/ stories/district_programs/Treasurer/revised%20version%20tps %20audit%20report%20june%204%202013.pdf. Accessed January 4, 2014.
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