Transforming eye care services: Evaluating the feasibility and utility of performing glaucoma assessments directly within care-homes and older peoples’ clinics

***Problem*** By 2050, 1M people will reside in UK care-homes. One-in-ten will have glaucoma, many of whom will struggle to attend hospital assessments due to high prevalences of complex-care needs. ***Solution*** Recently, a collaborative eyecare model for care-home residents has been developed by the co-applicants at Guy’s and St Thomas’ [GSTT]. Herein, care-homes, optometrists, GPs, and ophthalmologists work together to provide care-home residents with in-home vision assessments. Pilots (ongoing) indicate that such in-home-assessments are feasible for cataracts and AMD, and confer multiple benefits, including: faster assessments (mean time-away-from-room reduced from 6.1hrs to 32mins); more effective assessments (successfully completed visual-acuity/intraocular-pressure measurements increased from 72%/55% to 100%/100%, respectively); and reduced need for follow-up appointments (discharge rates increased from 8% to 32%). A range of other, additional benefits have also been noted, such as the ability of family members to attend/support, and savings in transport/carer costs (mean saving: £290/appointment). However, glaucoma (one of the most prevalent eye conditions in the care-home population) still remains difficult to assess outside of hospitals. This is particularly unfortunate as glaucoma is a chronic disease that requires lifelong monitoring, yet patients often remain stable for years at a time. It is simply not sensible or sustainable for all glaucomatous care home residents to travel to hospital once/twice a year, often to be told that no change in treatment is required. Separately, co-applicants at City, University of London [CITY], together with industry partners Irida Health, have assembled a set of portable tests for assessing glaucoma. This includes low-cost devices for assessing visual field loss (Eyecatcher) and peripheral-vision-related quality-of-life (Irida e-PROMs), as well as third-party structural measures of eye-pressure (iCare tonometer), and general eye-health (Remidio non-mydriatic fundus camera). Back-end architecture allows all measures to be automatically uploaded to a secure cloud-server for ophthalmic review. The present grant shall combine these two strands of inquiry: integrating the glaucoma assessment tools developed by CITY/Irida Health, into the collaborative, in-home eye care model developed by GSTT. The long-term goal is the delivery of a glaucoma eye-care model that maintains vision at lower cost and greater patient convenience. In addition, we shall also explore the feasibility of using these same portable tests to enhance multi-component falls-risk assessments currently ongoing at GSTT’s Older Persons Assessment Unit [OPAU]. The reasons are twofold: 1) to compare feasibility in outpatient vs care-home settings (i.e., to assess whether feasibility in the care-home population differs to the general older population). And 2) to assess whether integrating assessments of peripheral vision/eye-health helps improve fall-risk-identification. Falls are a preventable health issue both in and out of care-homes, and account for half of all accident related hospital admissions, at a national cost of over £2bn/year. Inferior visual field loss almost doubles the risk of serious falls causing injury. By embedding rapid, low-cost assessments of inferior visual field loss into onging falls-risk assessments, we hope to better identify individuals at particular risk of falls, as part of GSTT’s ongoing falls prevention strategy (for elderly people both in and out of care homes). ***Aims and Objectives*** With this grant we shall quantify the feasibility, acceptability, and value-for-money of (1) a novel, care-home based glaucoma assessment pathway, and (2) an enhanced fall-risk assessment program. Feasibility and acceptability will be quantified in terms of completion rates, assessment durations, and patient-/provider- satisfaction metrics. Reliability will also be assessed in terms of test-retest repeatability, agreement between measures, and, where available, agreement with prior medical data. Value-for-money will be assessed by performing a health economic assessment of the scheme, based on the above data (together with the cost of the equipment/personnel involved, and the expected long-term health benefits). ***Impact*** This work shall evidence more efficient and effective methods of glaucoma management & fall prevention. For the ~100,000 UK care-home residents with glaucoma expected by 2050, such changes will allow for more frequent and convenient glaucoma monitoring, while simultaneously reducing the strain on overstretched hospital eye services. While the related work in fall-risk identification will help to preemptively reduce incidents of serious and avoidable harm, both within care-homes and across the wider community.