Detroit Health Department
Vision to Learn Partnership
With a per capita income of $15,562, nearly 40% of Detroiters live below the poverty line. Detroit's population is 79.4% Black or African American, 9.5% White, and 7.5% Hispanic or Latino and is inside Wayne County, the second-most segregated county in Michigan. Wayne County also has the worst health outcomes (length of life, quality of life), and health factors (health behaviors, clinical care, social & economic factors, physical environment) in Michigan. Our city covers a very large area 142.9 square miles an area large enough that Boston, San Francisco, and Manhattan could all fit within our city's borders. Detroit's population has been shrinking for decades, going from 1.8 million people in 1950, to its current population of roughly 673,000.
Our population for this project was aimed at children 5 and older.
High rate of failed vision screenings:
Vision and Hearing screenings are State-mandated activities in Michigan. If a child fails one of our screening assessments, parents are notified, and they are referred for follow-up care. In Michigan, about 10% of children screened for vision are referred to specialists. In Detroit, that rate is far higher, with 17% of vision screenings resulting in a referral to a specialist.
Detroit's rate is alarmingly high, but to confirm whether our screening is accurate, children would need to receive an eye exam. This partnership was able to provide that.
Very low follow-up rate:
The number of children receiving follow-up care out of the number referred is the follow-up rate. In Detroit, we find that only 2% of our vision referrals result in follow-up care. This means that while we have a far higher rate of vision deficiencies, very few of our children are making it to a specialist for treatment.
The need for this type of effort was also underscored in the number of children who would fail our vision screenings year after year. When a child fails a vision screening, we send a letter home to notify the parent and refer them to services. The hope is that by the next year, when we rescreen the child again, they would have corrected vision and pass our screening. Instead, what we found was that 28% of the children that fail a vision screening fail again when rescreened the next year.
The American Academy of Ophthalmology estimates that for the first 12 years of a child's life, 80% of learning is visual. For so many of our city's children to have vision deficiencies, and for so few to be able to get the care they need, we were eager to get as much out of this partnership as possible.
Providing eye exams at the schools and delivering glasses to the schools also helps to address transportation issues so common to our city's residents.
The main goal of our practice is to improve the number of children receiving glasses, which we accomplished. There are a number of processes involved in doing so screening, distributing consent forms, collecting consent forms, eye examination, glasses ordering and distribution so it is important that we stay on top of these processes each step of the way.
While our partnership was very successful in Year 1, part of continuous quality improvement is that there is always room to improve. One of the greatest outcomes of our first year is the collaborative culture of quality that has been developed.
At the end of the school year, Detroit had the most eye exams of any city in their first-year of partnership with Vision to Learn.
To date, our partnership has provided over 4500 free eye exams for children, resulting in over 3700 glasses being distributed.
Detroit's children have a number of disadvantages. Compared to the big-city districts in the nation, Detroit regularly ranks at the bottom of the list. The Census ranks Detroit the poorest big city in the United States. Compared to the rest of Michigan, Detroit's children also have a far higher rate of vision referrals, with very few of these families able to get the follow-up care that they need.
Our target population are children 5 - 14 years old attending school in Detroit. In schools that participated in our program, 100% of children who fail their vision screening were given a consent form and referred to Vision to Learn for an eye exam.
Prior to partnering with Vision to Learn, we were only able to screen children and refer them for further care.
Through our partnership with Vision to Learn, we are able to provide children with free eye exams and glasses, at their school. It eliminates the issue of cost and transportation for the child and their family.
Vision to Learn is a California-based non-profit that has been providing glasses to children in low-income areas of the United States since 2012, and has since grown to serve more than 200 cities. What makes our practice innovative is our focus on continuous quality improvement, and the results thereof.
At the beginning of the year, our group meets for weekly calls where we review the metrics, go over the trends or issues that we are noticing, and discuss how we can correct the issues. After the meeting, we put out strategy into action and then review the changes at our next meeting. Through this Plan-Do-Study-Act process, we have been able to quickly develop more efficient processes. The result was the most eye exams VTL had performed in a city's first-year in the program.
Our work also focuses on the quality of service that the children receive. We have recently met with local ophthalmologists to develop a better plan for how to follow up with children who need additional care, beyond what Vision to Learn can provide.
To keep these difficult cases from falling through the cracks, we were also able to partner with local ophthalmologists if a child requires further care.
Our practice is based on best practices and state-recommended assessments. The DHD Vision and Hearing Specialists perform the Vision Screening Battery, as mandated by the State of Michigan. For pre-school and kindergarten students, this testing includes a Visual Acuity Test, Two-Line Difference Test, and the Stereo Acuity and Depth Perception Test.
For grades 1-9, this includes a Visual Acuity Test, Two-Line Difference Test, Plus Lens Test, Phoria Test, as well as looking for observable symptoms that require referral to a specialist (unequal pupils, droopy eyelids, crossed eyes, rapid eye movements, etc.).
Once the consent form is signed and returned, children receive an eye examination by trained optometrists on Vision to Learn's specially outfitted van.
We utilized several quality improvement and project management strategies in developing our program, including a detailed work plan to help guide us through accomplishing our objectives. Our work plan listed our objectives and the activities required for each objective. These were also assigned to individuals, along with a target date for completion.
Objective 1: Build and foster relationships with all proposed schools that we will be working with to prep them on the involvement in the Vision to Learn Program
Activities to accomplish objective 1:
- Develop screening schedule for Detroit Health Department Vision and Hearing Team for September â€“ December based on selection criteria (Priority â€“ Schools with recent screening results, followed by schools our team did not screen last year, followed by schools with high referral rates and low follow-up)
- Solidify consent form methodology by determining if we would like to use an electronic system/service or utilize paper consent forms and working with the individual schools to ensure their collection
- Solidify partners and funders of the Vision to Learn Program within the City of Detroit
- Work with superintendent(s), principals, and teachers to determine the extent of partnerships between Detroit Public Schools, Charter Schools, and Education Achievement Authority (EAA) schools in Detroit, the Health Department, and Vision to Learn. This includes solidifying and clarifying roles, developing timelines with individual schools and determining who within the schools we will be working most closely with to ensure the successful implementation of screening, eye exams, and glasses distribution.
Objective 2: Prepare for Kick-Off Eventâ€ to showcase Vision to Learn in Detroit Schools
Activities to accomplish objective 2:
- Work with principal and teachers to determine logistics of the Kick-Off Event
- Complete vision screening in initial school and send out consent forms to parents of children who need eye exams
- Hold Kick-Off event to begin eye exams in initial schools
Objective 3: Continue to screen, conduct eye exams, and give glasses to students in approximately 40 schools in Detroit to meet our goal of screening 25,000 children with approximately 5000 of those children being eligible for eye exams and glasses
Activities to accomplish objective 3:
- Re-evaluate screening schedule and make adjustments based on screening, consent, eye exam, and glasses turnaround/timeline from first few schools
- Develop screening schedule for January â€“ April based on selection criteria (Priority â€“ Schools we did not screen last year)
- Begin second semester (3rd quarter) screening
- Begin second semester (3rd quarter) eye exams and eyeglasses distribution
Each year, the Detroit Health Department provides vision screenings to pre-school children, kindergarteners, children in odd-numbered grades (1, 3, 5, 7, 9), and children in special education.
For the 2016-2017 school year (our first year partnering with VTL), we referred all children who failed our vision screening during 2016-17, as well as children who failed in the previous year. This allowed us to have all of the children with a failed referral to receive an eye exam and free glasses.
7/1/2016: Draft screening schedule for first 10 elementary/middle schools
7/15/2016: Have MOU between DPS, Vision to Learn, and DHealth agreed upon
7/22/2016: Reach out to selected schools to determine involvement
7/29/2016: Revise screening schedule based on input from school
Have final screening schedule for the first two quarters (Sept. - Dec.) determined
8/8/2016: Meet with initial school to determine logistics of Kick-Off event
8/15/2016: Have funders, partners, and sponsors verified for the 2016-2017 school year
8/31/2016: Have partnership agreements for each school that we are screening in the first two quarters complete
9/14/2016: Begin screening at first school
9/26/2016: Send out consent forms for students who did not pass screening
10/10/2016: Hold Kick-Off Event at first school and begin conducting eye exams
Our partners were great assets to us in setting this up. We had great buy-in from the Interim Superintendent of Detroit Public Schools (DPS), and our relationship with Detroit Public Schools has improved with time, even as both DHD and DPS went through periods of transition.
Our bi-weekly meetings are a chance to touch base with our stakeholders. We find that the aspect of teamwork is constantly emphasized, as we all need to work well together in order to get through all phases of this project.
To celebrate the first pairs of glasses being distributed, we hosted a kickoff event at the first school to receive eye exams. We had leadership from the Detroit Health Department, the founder of Vision to Learn, the Mayor of Detroit, and the Detroit Pistons all in attendance to help celebrate this partnership and all of the kids getting glasses. It's a great thing to see kids excited to get their first pair of glasses, and as a group of stakeholders, events like that can really help energize the partnership.
At the end of our first year together, representatives from Vision to Learn were able to come to Detroit and have an in-person meeting to review our year together, tighten up some processes we felt needed improvement, and review and revise our MOU to support our needs as a group moving forward. This meeting was a great chance to see the people who we were often only in contact with by phone or email, and I think we all left the meeting as a more cohesive group.
A strong relationship with DPS was important to our success. Large organizations can be difficult to navigate without having the proper relationships, but with DPS, this project was always made a priority.
We also depend heavily on VTL for the data to evaluate our progress together, and so it was important to have an easy reporting structure and a good relationship with our VTL counterparts to talk through when data needed correction or updates.
The vision screenings are a service mandated by the State, and we would be performing these services regardless of this partnership. Vision to Learn is a donation-funded non-profit with sponsors such as the Chan-Zuckerberg Initiative, The Ballmer Group, and dozens of others, including many professional sports teams. The main startup cost for this project was the van for eye exams, so from the beginning of this partnership, we planned out three years of working together. (Budget below)
VISION TO LEARN
DETROIT 3 YEAR SUSTAINABILITY
2016 2017 2018 2016-2018
Total Student/Patient Population 28,125
Scheduled For Exams (@15% of total) 4,000 * 4,500 4,500 9,000
Glasses (@ 80% of examined kids) 3,200 3,600 3,600 10,400
VTL Operations Cost
Optometrist ?1 56,000 63,000 63,000 182,000
Optician ?2 35,424 39,852 39,852 115,128
Eyeglasses-1 pair 70,400 79,200 79,200 228,800
Vehicle Fixed ?3 110,000 - - 110,000
Vehicle Operations ?4 4,000 4,500 4,500 13,000
Auto Insurance ?5 2,000 2,000 2,000 6,000
Management/Coordination ?6 76,260 78,105 78,105 232,470
Admin. Overhead ?7 24,408 26,666 26,666 77,740
Consultant ?8 50,000 - - 50,000
Operations Cost Total $ 428,492 $ 293,323 $ 293,323 $ 1,015,138
Medicaid Reimbursment ?9 0% 25% 50%
Exams with Glasses - 900 1,800
Exams only - 225 450
Medicaid Reimbursement Total $ - $ 109,832 $ 219,663 $ 329,495
Funding Required $ 428,492 $ 183,491 $ 73,660 685,643
* Partial year due to late start
?1 Optometrists: 3.5 exams an hour, $49/hour pay-rate, no benefits
?2 Opticians: 3.5 exams an hour+40% time for driving/setup/dispensing, $18/hour pay-rate, 23% benefits
?3 Equipped Vehicle cost - purchased outright in 1st year.
?4 Vehicle Operations(fuel, repairs, maint, wifi) is $1/exam per Jan-June overall VTL financials
?5 Allocated Vehicle insurance @ $2000/sprinter/year
?6 Full Regional Director salary and Program Coordinator Salaries
?7 Admin Overhead~10%(excl. vehicle fixed & Consultant) based on experience with overall VTL
(includes other insurance(D&O, GL, MPLI), Staff travel, Supplies, Printing/Stationery, Fundraising, Office expense, Audit/Tax/Accounting)
?8 Cost for Consultant to lead VTL efforts in Michigan
?9 Medicaid reimbursement @ Non-Facility fee rate
Our partnership leaves some consent forms at the school, in case teachers there are additional children that teachers suspect have poor vision. If these children get their consent form signed, they can get an eye exam just like the children that DHD refers. The problem that we saw in the first year was that at certain schools, teachers would make many copies of the consent form and distribute them to a large number of children. With too many of these teacher referralsâ€, we lose the advantage of pre-screening children. Also, with so many teacher referrals mixed in with DHD's referrals, it was difficult to tell how accurate our vision screening actually is.
In Michigan, about 10% of children fail a vision screening. In Detroit, that rate has always been much higher, around 17%. Detroit's high rate has occasionally been met with skepticism, so another benefit of this partnership was the ability to assess our screening accuracy. By having our referrals follow-up up with an eye exam, we can keep track of how many children receive prescriptions, and how many pass the eye exam. (Passing the eye exam would mean that we incorrectly referred the child.)
In evaluating our Vision screening results, we noticed some interesting results.
The LEA Vision Test is given to the pre-school and kindergarten children. This test is designed specifically for children who are unfamiliar with the alphabet, so children are shown shapes rather than letters. What we found was that 93.5% (202/216) of DHD's pre-school referrals with a signed consent form received a prescription. For kindergartners, 96.1% (445/463) of DHD's referrals with a signed consent form received a prescription. This means that DHD Vision screeners are more accurate in detecting vision deficiency in kindergartners than in pre-schoolers.
Grades 1-9 receive a more traditional vision screening (a Tumbling Eâ€ chart).
First grade: 93.7% of consented DHD referrals receive a prescription (817/872)
Third grade: 94.9% of consented DHD referrals receive a prescription (685/722)
Fifth grade: 95.8% of consented DHD referrals receive a prescription (746/779)
Seventh grade: 96.5% of consented DHD referrals receive a prescription (519/538)
Ninth grade: 100% of consented DHD referrals receive a prescription (75/75)
Grades 1-9 take a vision screening that shows a tumbling Eâ€ a capital letter E facing in different directions. For this age group, we see a clear trend of our screening becoming more accurate as we work with children in older grades.
These results show us two things. First, while there is room for improvement, it looks like our vision screeners are doing a good job of evaluating whether a child has a vision deficiency. Second, it seems that our ability to screen a child accurately may depend on outside factors, such as how well the children understand the instructions and the shapes or letters themselves. We see improved detection rates as age increases for both the LEA Vision Test, as well as with the traditional letter-based screening. The LEA was developed for children who cannot yet read, but considering the gap improvement between pre-school and kindergarten, it's possible that the younger children are having trouble understanding even the shape-based screening tool. More work would have to be done to confirm what the cause is, but based on feedback from our screening technicians, this seems plausible.
Considering that the LEA was developed to overcome possible comprehension issues with younger children, and considering the trend we see of increased accuracy as children get older, it seems possible that the trend we are seeing is being influenced by whether the children properly understand the symbols and directions of the test.
DHD's Vision and Hearing program has experienced deep budget cuts over the past few years, so the ability to assess our screening technicians helps strengthen our argument for funding from the State. It demonstrates that we are screening accurately, and confirms that our population has a great amount of need compared to other areas of the state.
DHD vision screening is a well-documented process, with statistics reported to the State on a quarterly basis.
For the number of eye exams completed, the number of glasses distributed, and the dates of these events, we relied on VTL to updated a shared spreadsheet on a weekly basis. These metrics were straight from their electronic medical record (EMR), and were collected as the children were provided service.
To date, our partnership has provided over 4500 free eye exams for children, resulting in over 3700 glasses being distributed.
To get the charter schools on board, we traveled to Lansing, Michigan to attend a meeting of the Michigan Council of Charter School Authorizers. We discussed and presented the partnership opportunity, spoke to the needs of our children, and the need for the MOU.
Our presentation was well-received by the attendees, and leaving the meeting we felt that we had the support we needed. This support did not trickle down to the schools, however, and we then had to email and call the schools individually to try to get commitments from more schools.
At the time, we were under the impression that the Authorizers had to sign for the schools. We later learned that was not the case, and that the Head Administrator of the school could sign. If we were to start from scratch, we would likely go to the schools directly.
There is sufficient stakeholder commitment to sustain this practice. We are currently in Year 2 of this partnership, and given the success of this program, will remain in this partnership for the foreseeable future.
Although Vision to Learn is well-funded through large donations, they would like to explore the option of billing Medicaid for their services, as they do in a couple of the cities they work in. This allows for a much more sustainable future, but it is not complication free.
For this option to go forward, parents would need to be properly notified that their insurance was being accessed, and explore all legal and ethical implications associated with doing so.
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