Eye health programs seeking to overcome equity issues prioritise the most marginalised remote communities, but what about disadvantaged people in urban areas? The first ‘in-reach’ service of its kind has launched in Australia, with a mission to eliminate disparities in metropolitan blind spots.
The Australian and New Zealand Eye Foundation (ANZEF) champions transformative research, education initiatives and advocacy projects that eliminate disparities in eyecare. Each year, the philanthropic division of RANZCO awards a handful of grants to standout projects that redefine the eye health landscape.
Dr Hessom Razavi and Dr Marcel Nejatian, of Lions InReach Vision (LIV) and recipients in the 2023 grant round, exemplified these principles with their one-of-a-kind eyecare service. Through LIV, they are reforming the health landscape in Metro Perth by providing comprehensive eyecare services to minority communities in this region. As a result, the duo were awarded the maximum grant value of $50,000 for their project.
Many of the barriers that minority communities experience when accessing Metropolitan healthcare services have been overlooked in the past. This can contribute to health disparities, including high rates of avoidable vision loss. To address these barriers and disparities, Razavi, a Western Australian ophthalmologist, established LIV which he operates alongside Nejatian, a junior doctor at the Lions Eye Institute (LEI).
“There can be a ‘blind spot’ in metropolitan areas of minority groups that face challenges with accessing mainstream eyecare services,” Razavi says.
Beginning formal operations in August 2022 in Midland, east-metro Perth, the clinic is servicing Aboriginal and Torres Strait Islander, refugee, and asylum seeker groups.
“These groups include people who need the most support for a variety of reasons. It’s not a single group and it’s not a single reason. It can be language, culture, financial issues. Often, it’s simply transport, medical problems and complex health needs. Oftentimes, it’s a variety of all those things,” Razavi says.
Razavi has amassed almost 10 years of experience working as a healthcare consultant for Indigenous patients. However, he decided to formalise these efforts into a dedicated service through LIV.
“To our knowledge it’s the first service of its kind in Australia. There are refugee services in South Australia and Victoria, but they are optometry only. Ours is the first to marry optometry with ophthalmology so that people have a ‘one-stop shop’ with easier access to specialist eye services,” Razavi says.
“We started off with targeting three groups: Indigenous patients, newly arrived refugees, and asylum seekers. And we’ve also had a trickle of patients coming in who have no fixed address – in other words, are homeless. We want to expand the service to comprehensively include those patients as well.”
As the recipients of the ANZEF grant round in 2023, the duo plan to extend the capabilities of the clinic further and diversify its service.
Full suite service
The clinic ensures a holistic model of healthcare whereby patients receive the full scope of eyecare. This makes it accessible and affordable for patients.
“It can take a year or more to see an ophthalmologist in a public hospital, which is where these patients generally get referred to. We’ve removed that barrier by making it collaborative care under one roof and by making it pro bono,” Razavi says.
With a comprehensive collaborative care model, Razavi also works to ensure all eyecare services are available to patients upon a single visit. It can be complex to manage, but worthwhile to avoid missed appointments and dropout.
“We’ve got an ophthalmologist, an optometrist to help with glasses, plus a junior doctor, nurses and ophthalmic technicians making up the team. Whether patients need a pair of specs, surgery, laser treatment or other medical treatment from me, or the combination of the two, the aim is to perform or arrange all of this in a single visit,” Razavi says.
“We know that attending appointments is often difficult for people in these situations. If they come as a family, then we offer to see the whole family in the room at the same time, which isn’t usually done in medical or specialist appointments.”
Successful delivery of services within these communities hinges on trust and cultural competency, with mandatory cultural awareness training for staff. Razavi emphasises the importance of fostering good relationships with community groups.
“It comes down to trust. We’ve got a long-term history with Aboriginal medical services in Perth and some in the regions. We’ve got good relationships with service providers for refugees and asylum seekers,” Razavi says.
“Refugees and asylum seekers come with an interpreter booked – and they’ll often have a caseworker in attendance.”
To ensure cultural safety, and using the funds from the ANZEF grant, LIV will soon appoint a dedicated patient liaison officer, who is a refugee themselves. This engagement with patients enhances the accessibility of the service and works to reduce failure-to-attend rates.
“The liaison officer will work with our patients, represent them, advocate for them and their needs, and help improve access to our service,” Nejatian says.
“For example, if a patient does not attend clinic, the patient liaison officer will call them and explore the reasons why. They would then make another appointment for them after addressing those barriers to attendance.”
For a highly tailored eyecare service, Nejatian says that liaison with advisory groups for each community will optimise the service further.
“We’re also developing separate advisory groups for the Indigenous and refugee populations, composed of community members and health workers.”
“We will meet with these groups and discuss what barriers these populations experience when accessing eyecare services, and how these barriers can be overcome.”
The underpinnings
With the ANZEF grant, the clinic will be able to employ the patient liaison officer for two days a week for two years. This builds on the initial funding for one day a week for two years contributed by pharmaceutical company Bayer.
“The ANZEF have been very generous with their grant. The support they’ve given us will help improve access to eyecare services for these populations. We’re using it to double the hours of our patient liaison officer, provide patient transport assistance, and fund our advisory group meetings and patient interviews,” Nejatian says.
“The ANZEF is doing a lot of amazing work in this area to improve access to services for vulnerable populations.”
In addition to ANZEF and Bayer, the duo also acknowledge support from St John of God Hospital in Midland, Australian Red Cross, the University of Western Australia (UWA) Optometry School, Derbarl Yerrigan Health Service and the Humanitarian Entrant Health Service.
Razavi hopes to double the frequency of clinics, which are currently running fortnightly. He also wants to expand to a second site.
“From January 2024 we’re going to offer consultations at the UWA Optometry School site in Nedlands. Patients could have the choice of being seen in Nedlands or Midland depending on where they live and what they need. Our goal is to enable all those forms of expansion,” Razavi says.
Nejatian adds: “We know there are other groups that face similar barriers, including people with disabilities, people from nursing homes, and people with no fixed abode. We hope to eventually expand to provide services for these groups as well.”
Currently, scaling the clinic to service all of Perth is not financially sustainable, Razavi says. He suggests that partnership from state and federal governments to expand the clinic into public ophthalmology departments to service neglected areas of Perth would work.
This would help serve at-need patients in other areas of Perth, as well as the Wheatbelt and Goldfields regions.
North Star
Razavi and Nejatian have conducted a preliminary analysis of the service to demonstrate its success to date, and to emphasise the need for expansion.
The analysis, as of October 2023 and presented at both the National Aboriginal and Torres Strait Islander Eye Health Conference as well as the RANZCO Congress, revealed a total of 409 clinic consults for 226 patients, 337 of which were ophthalmology-related, 42 optometry-related, and the remainder a combination of both. Of the 226 patients seen, 135 are Indigenous and 83 from a refugee background.
There have been 81 surgeries. The majority of these have been cataract surgery, including two patients blind in both eyes and six patients blind in one eye who are no longer blind after removal of their cataracts.
Approximately 170 intravitreal injections have been performed, mostly for diabetic retinopathy in the Indigenous population.
“Clearly, there is a need for these services. As the clinics are getting quite full, we’re hoping to expand further so that we can provide even more in future,” Nejatian says.
Razavi adds: “Our ‘North Star’, or the guiding principle, for LIV is ‘proportionate universalism’.
“This is the idea that, ultimately, we want to provide universal eyecare for all – with expertise and resources directed proportionally based on need. In other words, all patients will be looked after, and those that need extra support will receive it.”
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