U.S. Department of Health and Human Services

Chapter 9 - Eye Care Program

Part 3 - Professional Services

Title	Section
Introduction	3-9.1
Purpose	3-9.1A
Policy	3-9.1B
Indian Health Service Eye Care Program	3-9.1C
Eye Care Organization	3-9.2
Indian Health Service Eye Care Clinical Consultants	3-9.2A
Service Unit Eye Care Organization	3-9.2B
Staff Credentials	3-9.2C
Continuing Education	3-9.2D
Ad Hoc Committees and Workgroups	3-9.2E
Eye Care Program Policies and Procedures	3-9.3
Indian Health Service Direct Care	3-9.3A
Purchased/Referred Care	3-9.3B
Division of Services	3-9.3C
Health Promotion/Disease Prevention	3-9.3D
Prescription Ophthalmic Devices	3-9.3E
Indian Health Service Medical Priority System	3-9.4
Indian Health Service Medical Priority System	3-9.4A
Schedule of Services	3-9.4B
Standards of Operation	3-9.5
Medical Records	3-9.5A
Scheduling	3-9.5B
Indian Health Service Eye Care Performance Improvement Program	3-9.5C
Research	3-9.5D
Equipment	3-9.5E
Optometric Clinical Training Program	3-9.5F
Staffing Standards	3-9.5G

Manual Exhibits	Description
Manual Exhibit 3-9-A, [PDF - 107 KB]	“School Vision Screening”
Manual Exhibit 3-9-B, [PDF - 139 KB]	“Diabetic Retinopathy Screening/Monitoring”
Manual Exhibit 3-9-C, [PDF - 110 KB]	“Primary Eye Care Examination Standards”
Manual Exhibit 3-9-D, [PDF - 155 KB]	“Standard Ophthalmic Equipment List”

3-9.1 INTRODUCTION

Purpose. This chapter sets policies and procedures, staffing responsibilities, priorities of care, services provided, and general standards of operation for the Indian Health Service (IHS) Eye Care Program.

Policy. It is the policy of the IHS to provide quality eye care to American Indian and Alaska Native (AI/AN) people through comprehensive and culturally acceptable eye care services.

IHS Eye Care Program. The program will include:
1. Ocular health promotion activities;
2. General and specialty examinations;
3. Treatments and procedures;
4. Required prescription ophthalmic devices and associated dispensing services; and
5. Ophthalmic surgery.

3-9.2 EYE CARE ORGANIZATION

IHS Eye Care Clinical Consultants.
1. Optometry Chief Clinical Consultant. The incumbent is an IHS Clinical Optometrist, Chief Clinical Consultant, and spokesperson for IHS Optometry and is appointed by the IHS Chief Medical Officer (CMO). Issues of an inter-professional nature or which have programmatic direction will first be discussed by the IHS Eye Care Coordination Committee. By virtue of being appointed to the position of Chief Clinical Consultant, the person becomes a required member of the IHS Eye Care Coordination Committee (See IHS Circular 23-08).
  
  Some specific responsibilities of the Optometry Chief Clinical Consultant are as follows:
  1. Liaison to IHS Headquarters on special activities such as the IHS Loan Repayment Program, career development, Commissioned Officer Student Training and Extern Program (COSTEP), IHS Scholarship Program, etc.
  2. Provides guidance and consultation to the Area optometry consultants.
  3. Directs or assists in the coordination of optometry committee activities.
  4. Oversees the optometry externship and residency programs.
  5. Directs or assists in the coordination of optometry recruitment.
  6. Participates in the development of IHS staffing and planning documents.
  7. Provides guidance for optometry credentialing, privileging, and peer review.
  8. Representative for IHS optometry at IHS and non-IHS professional meetings.
2. Deputy Optometry Chief Clinical Consultant. The Deputy Optometry Chief Clinical Consultant is an IHS Clinical Optometrist appointed by the IHS CMO to assist the IHS Optometry Chief Clinical Consultant as needed. By virtue of being appointed to the position of Deputy Optometry Chief Clinical Consultant, the person becomes a required member of the IHS Eye Care Coordination Committee (See IHS Circular 23-08).
3. Ophthalmology Chief Clinical Consultant. The Ophthalmology Chief Clinical Consultant is an IHS Clinical Ophthalmologist appointed by the IHS CMO. The selected person is the Chief Consultant and spokesperson for IHS ophthalmology. Issues of an inter-professional nature or matters which have programmatic direction will first be discussed by the IHS Eye Care Coordination Committee. By virtue of being appointed to Ophthalmology Chief Clinical Consultant, the person becomes a required member of the IHS Eye Care Coordination Committee (See IHS Circular 23-08). Some specific areas of responsibility are as follows:
  1. Chief liaison to IHS Headquarters on special activities such as the Loan Repayment Program, career development, and all other programs that have an impact on IHS Ophthalmology services.
  2. Participates in the development of IHS staffing and facilities planning documents.
  3. Provides guidance, consultation, and troubleshooting to Service Units (SU) and IHS ophthalmologists.
  4. Provides input on ophthalmology performance improvement, credentialing, billets, and privileging, research, ocular surgery, and primary care.
  5. Liaison for the American Academy of Ophthalmology and other professional groups.
4. Deputy Ophthalmology Chief Clinical Consultant. The Deputy Ophthalmology Chief Clinical Consultant is an IHS Clinical Ophthalmologist appointed by the IHS CMO to assist the IHS Ophthalmology Chief Clinical Consultant as needed. By virtue of being appointed to the position of Deputy Ophthalmology Chief Clinical Consultant, the person becomes a required member of the IHS Eye Care Coordination Committee (See IHS Circular 23-08).
5. Area Consultants. Each IHS Area will appoint an Area Ophthalmology and an Optometry Consultant, if available. All Area Consultants will provide consultative services to the appropriate governing body. Input from eye care Area Consultants may be needed in many areas of program management and should be consistent with IHS policy. Area Consultants may provide input on:
  1. Program and facilities planning;
  2. Clinical care;
  3. Recruitment,
  4. Program reviews;
  5. Troubleshooting;
  6. Communication/reporting; and
  7. Performance improvement/peer review.

Service Unit Eye Care Organization.
1. Chief of Optometry, Service Unit (SU). Supervises the optometric staff within the SU.
2. Chief of Ophthalmology, SU. Supervises the ophthalmology staff within the SU.
3. Chief of Eye Care Services, (SU). Where optometry and ophthalmology services are provided at the same facility, the program may be directed/coordinated by a Chief of Eye Care. Selection of an appropriate ophthalmologist or optometrist should be based upon possession of the proper credentials including administrative experience, availability, and willingness to do the job.

Staff Credentials. All eye care providers must adhere to their facility’s credentialing and privileging requirements. An important component of the credentialing process is peer assessment of the providers’ qualifications as presented in their applications for clinical privileges and subsequent ongoing peer reviews. Peer reviews will be completed annually and according to agency policy and each facility’s accreditation requirements. Guidance may be obtained from the Area Optometry Consultant or Area Ophthalmology Consultant, as appropriate.

Continuing Education. Continuing education is essential for the individual practitioner to maintain clinical competence and licensure. It may be obtained through approved individual study and/or through a variety of mechanisms including local, regional, or national meetings within or outside the IHS. The eye care professional must meet the continuing education requirements of the relevant licensing board(s) to maintain their professional licensure and satisfy local medical staff requirements. Financial support for this may be available.

Ad Hoc Committees and Workgroups. Optometry and Ophthalmology utilize committees to address issues such as:
1. Diabetes;
2. Pharmacotherapeutics;
3. Research;
4. Training;
5. Career development;
6. Recruitment;
7. Special pay; and
8. Planning/review for staff, space, equipment, etc.

3-9.3 EYE CARE PROGRAM POLICIES AND PROCEDURES

IHS Direct Care.
1. Eligibility. All persons who are eligible for general medical care through the IHS health care delivery system are eligible for eye care, subject to expressed limitations in this section and other IHS regulations.
  1. Patients are encouraged to seek care at their respective SU.
  2. Where direct care is not available and/or where supplemental or specialized care may be required, it may be procured under contractual arrangements by appropriate IHS authorizing officials, consistent with current priorities.
2. Frequency of Examination. The frequency of eye examination shall be determined by the individual needs of each patient.
3. Screening. Children (through age 18) should be screened each year. This can be done by trained staff in schools (for school-age children) or in different facility departments, i.e., primary care or pediatrics.
4. Complete Examinations. Complete exams should be performed by an optometrist/ophthalmologist yearly for children, every two years for adults up to age 60 and yearly after the age of 61 (American Optometric Association (AOA) Clinical Practice Guidelines). More frequent examinations are encouraged when:
  1. Signs or symptoms of acute or chronic eye disease/conditions are known or apparent;
  2. Instructed by a provider to return for a specific reason;
  3. Referral from a doctor, school nurse, or school screening; and
  4. Significant visual symptoms are apparent.
5. Diabetic Screening and Monitoring System. A diabetic screening system will be maintained whereby every diabetic in the eligible population is encouraged to have an adequate ocular health screening/examination at least once a year (AOA Clinical Practice Guidelines). (See Manual Exhibit 3-9-B, Diabetic Retinopathy Screening/Monitoring.)
6. Emergency Care (Non-AI/AN). Emergency care can be provided to non-eligible people for sight-threatening conditions to achieve stability. Where such care is provided, billing is done in accordance with applicable IHS regulations.

Purchased/Referred Care. General, supplemental, and/or specialized care may be procured under contracts consistent with current policies. All IHS personnel who refer patients to non-direct care eye care providers must familiarize themselves with IHS Purchased/Referred Care (PRC) rules, regulations, and priorities.

Division of Services.
1. Primary Eye Care Services. Entry to eye care services generally occurs through direct care and contract care optometry/ophthalmology clinics. The level of services provided at any given direct care facility is dependent upon the eye care personnel available and the level of services provided.
2. Secondary Eye Care. Secondary level services are provided in conjunction with medical priorities, availability, and in accordance with IHS rules and regulations. Services include:
  1. Management of complicated ocular conditions and injuries.
  2. Consultative services when available with other health care providers.
  3. Contact lens examinations and evaluations.
    1. Non-elective contact lenses. When ocular conditions exist that preclude the successful use of ordinary eyeglasses, contact lens fitting may be authorized. Most commonly, these applications are for keratoconus; irregular astigmatism correction; anisometropia (where symptoms are present or where it can be documented that binocularity will be significantly enhanced); and high refractive error. A written referral from an IHS optometrist or ophthalmologist may be required if a PRC provider is utilized.
    2. Cosmetic or elective. All other contact lens examinations will be considered elective. Elective contact lens fitting (including evaluation fees, materials, insurance, re-check visits, and the like) is not authorized by PRC priorities. Where direct IHS eye care is available, contact lens examinations and evaluations may be authorized. All costs incurred for lenses, insurance, and other accessories are the responsibility of the patient. If contact lenses are to be prescribed, adequate contact lens assessment equipment must be on hand.
3. Vision Therapy/Orthoptics. Vision therapy and/or orthoptics may be accomplished by or under the direction of an IHS optometrist or ophthalmologist where appropriate. Vision therapy/orthoptics scheduled to be performed by a contract provider requires prior written referral from an IHS optometrist or ophthalmologist if a PRC provider is utilized. These services may be reviewed periodically for efficacy.
4. Eye Surgery. All eye surgery performed should be consistent with IHS priorities and regulations. (See Section 3-9.4 B.) Any PRC referrals should be consistent with the same priorities and applicable regulations. Records should be kept of all patient surgeries.
5. Low Vision Services. Low vision evaluation and the necessary devices will be available to patients based on the available staffing and level of services provided. The PRC referrals should be used if services are not available.

Health Promotion/Disease Prevention.
1. Vision Safety/Employee Health. In accordance with Executive Order 12196, “Occupational Safety and Health Programs for Federal Employees,” and Public Law (P.L.) 91-596, Part 29, Section 19, Code of Federal Regulations 1960, “Occupational Safety and Health Act, 1970,” the IHS will establish and maintain a viable vision safety program for its employees. Each Service Unit will be in compliance and will incorporate this program into its Employee Health Plan. The IHS eye care providers at the respective Service Unit will provide assistance to these programs as requested.
2. Eye Screening.
  1. It is optimal to complete school vision screenings for AI/AN children annually if staffing and resources permit. (See Manual Exhibit 3-9-A, “School Vision Screening.”)
  2. Ocular health screening of all diabetic patients in compliance with screening protocol is recommended. This screening should be provided by eye care professionals or through the Indian Health Service/Joslin Vision Network (IHS/JVN) Teleophthalmology Program as part of routine diabetic care. When identified, patients with diabetic retinopathy should be monitored by eye care professionals and/or the IHS/JVN Teleophthalmology Program depending on the extent of disease and availability of eye care professionals. All diabetic eye disease requiring treatment should be referred to eye care professionals. (Manual Exhibit 3-9-B “Diabetic Retinopathy Screening & Monitoring Procedures.”)
  3. Other types of ocular screening may be recommended by local eye care professionals based upon endemic need. The design and method of any screening performed should be appropriate to the target population.
3. Patient Education. Patient education is the cornerstone of health promotion and its impact on community health care cannot be overemphasized. While a great deal of patient education occurs during the one-on-one encounter of provider and patient, an eye care educational program would benefit each IHS facility and program area. In addition, IHS-approved AI/AN-specific eye care education pamphlets and posters may be used for distribution to patients and clinics through IHS health care programs.

Prescription Ophthalmic Devices. When prescription ophthalmic devices are provided using IHS funds, the following provides a reasonable and equitable guideline for the utilization of these resources.
1. Eye Glasses. No eyeglasses should be ordered or replaced unless the ocular condition or the condition of the eyeglasses is warranted. Care should be exercised in avoiding the use of eyeglasses that would provide minimum benefit, unless indicated for safety reasons (i.e., monocular patients).
2. Frequency of Eye Glass Replacement and Prioritization.
  1. Children through age 18 or through 12th grade should be allowed one pair of eyeglasses in any 12-month period and/or at the discretion of the provider.
  2. Adults will be limited to one pair of eyeglasses in any 24-month period and/or at the discretion of the provider.
  3. The one-year/two-year limits of eyeglass replacement at IHS expense applies within the context of the current facility’s or Area’s policy.
  4. Records will be maintained by all eye clinics/facilities indicating when a patient last received eyeglasses at IHS expense.
3. Limitations in Eyeglass Provisions.
  1. Frame costs will be established by the facility/SU or IHS Area depending on local and regional availabilities and funding.
  2. Tints and other eyeglass accessories will only be provided at the discretion of the provider when clinically indicated.
  3. No cosmetic lenses will be routinely provided at IHS expense.
  4. Before a non-IHS eyeglass prescription is filled at IHS expense, the patient may be requested to have the prescribing doctor complete an information form or to supply added information on the prescription. Information that may be requested includes the following:
    1. Prior prescription; condition of glasses.
    2. Visual acuity without glasses, distance and/or near.
    3. Visual acuity with old glasses, distance and/or near.
    4. Visual acuity with new glasses, distance and/or near.
  5. Eyeglass prescriptions that are current will generally be accepted.
  6. Eyeglasses at IHS expense will be procured through appropriate government acquisition route(s). Exceptions may be allowed for individuals temporarily residing outside of and at a substantial distance from their SU, such as, at a college or vocational school, providing the person meets all qualifying IHS regulations.
4. Quality. All eyeglasses will be verified for accuracy of prescription and quality of workmanship utilizing the ANSI Z-80 and/or Z-87 optical standards before dispensing.
5. Contact Lenses.
  1. Therapeutically Indicated Contact Lens. Under conditions where therapeutically indicated contact lenses must be purchased, the initial contact lenses and the minimum required accessories may be purchased with IHS funds, subject to priority limitations, within the following conditions:
    1. Initial and replacement solutions may be provided consistent with pharmacy over-the-counter drug policy.
    2. Lenses will be replaced or updated as the individual patient’s eye condition dictates.
  2. Cosmetic/Elective Contact Lenses. Expenditure of IHS funds is not authorized, however, alternate funding is encouraged, e.g., patient-paid and Lions Club.
6. Low Vision Devices.
  1. If sufficient resources are available, entry-level low vision services should be available at IHS facilities. Low vision devices for patients with documented low vision needs, including Occupational and Orientation & Mobility Training should be provided at IHS expense, if within IHS priorities of care.
7. Prosthesis. Prosthetic eyes/shells, when integrally related to surgery or where there is gross (socially unacceptable) disfigurement, will be provided consistent with current IHS priorities. Replacement is based on the physiological needs of the patient and is at the discretion of the provider.
8. Payments. When funding is not available for purchase of an ophthalmic appliance, especially when this device is most appropriately ordered through specialty sources and is not otherwise available locally, the eye clinic or another facility department may act as an intermediary for the purchase of the item by coordinating and facilitating payment by the patient to the source. The form of payment, i.e., money order, debit card/credit card, is determined by collections policy within each IHS Area and in accordance with local policy.

3-9.4 INDIAN HEALTH SERVICE MEDICAL PRIORITY SYSTEM

This section describes the services which are provided in the IHS eye care delivery system. These services have been subdivided into five levels of services. The provisions of services necessary to treat emergency situations, those which are preventive, and those which promote eye health are classified higher than those which are corrective, rehabilitative, or supportive. For example: Level I services are the most necessary services, and Level V services are excluded services.

The schedule of services in Section 3-9.4 B is intended to serve as a guide for: Eye care provider’s fee-for-service eye care providers; administrators of eye care programs; third-party administrators; and PRC personnel. Tribes operating pursuant to P.L. 93-638 contract may choose to adopt this schedule of services. Each schedule of services is a distinct and acceptable method of eye care delivery to AI/AN patient populations.

Indian Health Service Medical Priority System.
Referred Care is administered and directed by policy set forth by PRC. The delivery of Referred Care for the Eye Care Program will follow the Indian Health Service Medical Priority Levels.

For the internal administration of Eye Care Services, a priority system (Schedule of Services) for eligible patients has been established based upon the levels of services. If the need for services exceeds the available resources, services should be provided in the descending order of the level of care. When increasing services, each priority should be fully met before proceeding to the next lower priority within any given level. Adequate time/resources must be available to permit associated performance improvement and statistical data activities required for program management relative to each level of services provided.

All facilities should develop a means to adequately screen all appointment requests in order to determine each patient’s relative priority and to help reduce the chance of deferring a patient with an urgent or sight-threatening eye condition.

The ability to provide eye care at a given priority level will vary significantly between Areas/SUs due to demand, staffing, and financial resources. The Area/SU priority level may need to be changed frequently in response to backlog and other factors. Each facility’s current IHS Medical Priority System level shall be documented and approved by the SU/facility director. Documentation of these changes and changes in priorities will be forwarded to the respective Area Consultant.

Schedule of Services. The elimination of any component of Levels I, II, or III, may significantly compromise the efficacy of any eye care program and create risk management and public health liabilities.
1. Level I. Services necessary for relief of acute conditions or services sufficiently urgent to warrant the highest level of priority.
  1. Emergency Services. Services necessary to prevent the immediate loss of an eye or vision in an eye, i.e., penetrating injuries, open eye injury, chemical burns, central retinal artery occlusion, acute angle closure glaucoma, and retinal detachments threatening the macular area.
  2. Urgent Services. Those services necessary for relief of acute, painful, or visually threatening conditions, i.e., corneal foreign body or abrasion, corneal ulcer, iritis, or any diagnosed/undiagnosed condition which could result in rapid vision loss if not given proper attention.
  3. Specialty Consultations. In instances where no direct medical care is available, it may be necessary to authorize consultations through PRC to establish diagnoses (this is not necessarily a referral for treatment and/or monitoring). As the result of a PRC referral to a provider outside HIS, once a diagnosis is confirmed, the patient will be treated consistent with the level of services currently being provided.
  4. Diabetic Retinopathy Screening & Management. Diabetic retinopathy monitoring and treatment programs.
  5. Glaucoma Screening & Management.
2. Level II (High Priority Restorative and Preventive Eye Care Services). Those services and activities designed to restore vision in the event of severe binocular vision loss, prevent the onset or progression of ocular disease or visual impairment, or services to advance the ability of people to become self-reliant.
  1. Vision Restoration. In the event of a progressive/degenerative eye condition, services to restore vision should be considered, and appropriate referrals made. Besides appropriate surgery/procedures, low vision aids and protective eyewear for functionally monocular patients should be considered.
  2. Children Screening Programs. Organized eye screening and treatment programs for children through age six.
  3. Management of Sub-acute or Chronic Conditions. Include but not limited to:
    1. Keratoconus management;
    2. Amblyopia/functional strabismus management;
    3. Ocular prosthesis or other cosmetic restoration of badly disfigured patients;
    4. Routine surgical care;
    5. services and follow-up of Level I services; and
    6. Therapeutically indicated contact lenses.
3. Level III (Other Primary Eye Care Services and Priority Secondary Eye Care Services). Care required to improve an impairment of function that is still adequate.
  1. Eye examinations for children ages 5-18 or through 12th grade.
  2. Eyeglasses for children through age 18 or through 12th grade.
  3. Vision Safety Program. The IHS eye care provider will provide assistance to programs as requested.
  4. Eye care for adults (prioritized): As approved for the visual condition/needs.
4. Level IV (Other Rehabilitative Services and Elective Services). Services that do not address a functional deficiency in accordance with local policy. Optometrists and ophthalmologists may perform a number of procedures within these services, consistent with their privileges. Rehabilitative services that require more time, additional skill of the provider, or a higher cost to benefit ratio, including but not limited to:
  1. Minor and cosmetic surgical procedures;
  2. Cosmetic contact lenses; and
  3. Vision therapy/orthoptics.
5. Level V (Excluded Services). Excluded services include cosmetic procedures and experimental procedures that are excluded from authorization for PRC payment. Medical Excluded Services shall be based on the Centers for Medicare and Medicaid (CMS) Medicare National Coverage Determinations Manual. Services of an experimental/investigational nature or of questionable efficacy, or procedures that have an acceptable non-invasive alternative, such as use of placebo eyeglasses, refractive surgery, and asymptomatic blepharoplasty are Excluded Services.

3-9.5 STANDARDS OF OPERATION

Medical Records.
1. Strict adherence to the intent and the specific provisions of the Privacy Act is mandatory.
2. Adequate eye care records, as part of each patient’s general health record, is essential.
3. The recording and coding of eye examinations must comply with IHS records requirements and IHS Electronic Health Record policy.

Scheduling. A patient scheduling policy will be made available to patients in all facilities and strictly used to govern appointment/scheduling procedures. At minimum, this policy should include:
1. Clinic hours;
2. Availability of emergency care after hours;
3. Routine appointment making procedures;
4. Appointment priorities and justification if different from IHS or Area policies;
5. Walk-in policy;
6. Late and no-show policies;
7. Referral policy and sources; referral follow-up; and
8. Specialty clinics.

Indian Health Service Eye Care Performance Improvement Program. The intent of the IHS Eye Care Performance Improvement (PI) Program is to provide an active, organized, peer-based procedure for maximizing the quality of patient care. Among the goals of the PI Program is adherence to the principles of the accrediting agency. The PI Program should include at least the following elements:
1. Program Review. The Area Ophthalmology and Optometry Clinical Consultants are responsible for the development, implementation, and application (as requested) of a program review that addresses:
  1. Assessment of the administrative direction of the program;
  2. Organization and functioning of the eye clinic within the overall facility framework;
  3. Policies and procedures of the eye clinic that should be reviewed annually and updated in accordance with facility policy;
  4. Staff membership status and clinical privileges of the professional staff of the eye clinic;
  5. Physical facility and equipment;
  6. Paraprofessional staffing and utilization;
  7. Research and educational activities;
  8. Continuing education program;
  9. Peer review program; and
  10. Provider profiles.
2. Peer Review. Area Ophthalmology and Optometry Clinical Consultants are responsible for assuring that a peer-review PI Program for each SU in the Area is developed and implemented. The PI audit program should include:
  1. A written Eye Care PI Plan;
  2. Organized clinical criteria and standards against which performance may be objectively measured;
  3. Objective, documented assessment to assure compliance with established criteria and standards;
  4. Peer review of the appropriateness of care;
  5. A mechanism to identify problem areas;
  6. A procedure for developing a recommended plan of corrective action;
  7. A feedback mechanism to assess whether identified problems are corrected by implementation of appropriate action;
  8. A policy to deal with a disagreement with peer review; and
  9. Written documentation of each requirement (above) that requires the Eye Care Program to participate in the facility PI Program as directed through the facility PI Plan.
3. Service Unit Review. The SU Chief Clinical Consultant is responsible for the development and implementation of the SU Eye Care PI Program. This program will include a written SU Eye Care PI Plan as outlined above, as well as an ongoing assessment of the care provided through the use of generic screens and/or focused surveys, as recommended by the SU PI coordinators.
  1. There must be written documentation of ongoing assessments.
  2. Formal problems are identification and resolution, usually within the framework of the facility's PI group, shall be documented.
  3. Productivity standards will vary from clinic to clinic depending on the type of patient typical to that clinic, the equipment, and the support staff. Assessment of levels of productivity should be done in collaboration with the appropriate discipline consultant.
4. Primary Eye Care Exam Standards. Practice guidelines have been established for a primary eye care exam. (See Manual Exhibit 3-9-C.)

Research.
1. Research on visual and ocular problems and conditions is encouraged. Appropriate research that will increase the understanding of the visual ocular conditions of AI/AN people and/or improve the delivery of eye care is highly encouraged.
2. Resources for IHS research may be available.
3. All projects must follow protocol for approval as established by Part 1, Chapter 7, "Research Activities," Indian Health Manual.
4. Research activities shall not compromise or conflict with the provision of core services.

Equipment.
1. Standard Eye Care Equipment List. The standard eye care equipment list is the result of continuous evaluation and revision by Senior Clinicians and IHS specialty consultants. The list was developed to aid in equipment acquisition for new facilities but will be useful as a guide to equip existing facilities. Discussions with the SU or IHS Area biomedical officer are recommended. By regulation, the equipment purchased must be from government contract sources; a request for purchase from other sources must be accompanied by a detailed justification.
2. Standard Eye Care Equipment List Update. Improvements in ophthalmic equipment and technology require that the eye care equipment list be subject to frequent review. Discussions with the SU or IHS Area biomedical officer are recommended. Suggested revisions must be directed by the Area optometry and ophthalmology consultants, with recommendations, to the IHS Chief Clinical Consultant whose responsibility it is to update the ophthalmic equipment list. (See Manual Exhibit 3-9-D.)
3. Preventive Maintenance. An ongoing preventive maintenance program is essential to clinic efficiency and prevents interruption of patient care services due to equipment failure. Generally, major ophthalmic equipment will have preventive maintenance in accordance with the manufacturer’s recommended maintenance schedule and the facility’s accrediting agency requirements. This can be effectively provided through an IHS Area-level maintenance contract.
4. Repair and Replacement. Replacement and/or repair of specialized eye care equipment will be carried out on an as needed basis.

Optometric Clinical Training Program. Although clinical training is not a primary function of the IHS, IHS facilities may participate in clinical training programs with accredited academic institutions when beneficial to patient care and program goals.
1. Optometric Student Externships. Sites that have clinical space, i.e., an equipped examination room available full-time to the extern, and adequate patient caseload, are encouraged to host senior optometry students for clinical rotations. A Memorandum of Agreement signed at the Area level and by the respective school(s) or college(s) of optometry from which students are assigned, governs the operation of these rotations. Students are granted limited privileges requiring co-signature by fully privileged staff. In addition to increasing access to care for patients, these rotations create a positive reputation for the IHS, enhance recruitment, and stimulate staff morale and career satisfaction.
2. Optometric Post-Graduate Clinical Rotations. Optometric post-graduate clinical rotations, also called Optometric residencies, may be sponsored by IHS optometry programs and must be affiliated with a school or college of optometry. As with student extern programs, clinical space and clinical caseload must be appropriate to support such programs and an agreement with the certifying academic institution signed at the IHS Area level delineates operation. Residents are privileged to practice independently as members of the medical staff according to their licensure and credentials. In addition to increasing access to care for patients and generating revenue for IHS facilities, these rotations create a positive reputation for the IHS, enhance recruitment, and stimulate optometric staff morale and career satisfaction.

Staffing Standards.
1. Optometry staffing will be maintained at levels necessary to carry out basic IHS Optometry Services.
  1. The total number of positions required to manage and deliver optometric care should be reviewed every two years.
  2. The Resource Requirements Methodology (RRM) optometry staffing module estimates the requirements for optometrists and support staff (technicians/assistants) to deliver appropriate optometric care. The workload parameters that are the key variables in the staffing estimation are actual workload data and average daily patient load (utilization rates), which should be reviewed every two years. (See IHS manual-RRM references for ambulatory clinics)
  3. Optometry positions, both professional and support staff, should be under the general supervision of the Chief Optometrist. This individual must be a licensed optometrist. In the Chief's absence, another licensed optometrist should be designated as Acting Chief Optometrist, or other individual as appropriate.