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Cooperative Agreement

Prevent Blindness America

In 2008, CDC established a 3-year cooperative agreement (CA) with the Prevent Blindness America (PBA), a leading voluntary health organization dedicated solely to the prevention of vision loss and the preservation of sight. This CA will involve multiple parties across four separate, yet integrated components. The program and research teams include Duke Clinical Research Institute (DCRI), Johns Hopkins Bloomberg School of Public Health (JHBSPH), New York State Department of Health (NYSDOH), Prevent Blindness North Carolina (PBNC), Prevent Blindness Ohio (PBO), and Prevent Blindness Tri-State (PBTS).

  1. Examine intervention models to identify and reach high risk individuals for vision disorders
    1. Adults screening:
      1. To determine if a two part screening evaluation for ocular diseases among primary care patients of Federally Qualified Heath Centers (FQHC) and Free Clinics in Columbus and Cleveland, Ohio can effectively identify persons who need eye care services.
      2. To assess the cost of identifying persons with vision problems in these heath care settings.
    2. Pediatric screening:
      1. To evaluate strategies for the detection of amblyopia in the primary care settings.
      2. To quantify the benefit of school-based vision screening.
  2. Develop methods to integrate and link vision public health initiatives to state, local, and community health programs
    1. To integrate appropriate and effective vision health strategies into existing public health programs within state health departments.
  3. Evaluate and expand vision health data systems

In 2003 CDC awarded Prevent Blindness America, a national non-profit vision organization, a five year cooperative agreement to further develop a national vision loss prevention program including surveillance, economic studies, and opportunities for state-based approaches to reduce the burden of vision loss and eye diseases. Over the course of this partnership, Prevent Blindness America, along with its network of affiliates and regional offices established new programs in vision preservation aimed primarily at adult populations. Key to this effort’s success was initiatives to ensure appropriate follow-up care; the development of a national data collection system; a successful partnership with the National Association of Chronic Disease Directors; public education through state-based vision symposia; participation in the expansion of the optional vision module of the Behavioral Risk Factor Surveillance System; strategies to integrate vision and eye health into state public health systems; engagement of the primary healthcare system in addressing vision and eye health; and expansion of programming to new territories throughout the country. Examples of some of these state-based programs, along with key national efforts that have expanded the capacity of the organization to deliver upon its mission are highlighted below.

Click here [PDF–159KB] for the complete five year report.


National Data Collection System

A critical first step in PBA’s cooperative agreement with CDC was to develop a national database for the uniform reporting and collection of screening information. With a standardized database, population targeting, tracking to referrals treatment, and program evaluation become possible. As data begins to be collected in a uniform and systematic manner, vision preservation programming can be more effectively measured and evaluated, leading to key improvements and modifications in program design. In 2004, the first phase of this internet-based system became available for use by Prevent Blindness America certified screeners and training on the database became a critical element of Prevent Blindness America vision screening training programs. Since that time, numerous iterations have been developed to allow the program to become more user-friendly and to expand its scope to fully address the variety of screening and follow-up programs being delivered. Because of this database and its improvements over the course of this cooperative agreement, Prevent Blindness Georgia is now able to utilize the data collections system not only to track its vision screenings, but also to enter data specific to the follow-up exams it conducts during its clinics.
 

Behavioral Risk Factor Surveillance System

In order to effectively establish programs of care, the gathering of epidemiological data is essential. An important mechanism for collecting state-specific data that can help shape prevention activities is the Behavioral Risk Factor Surveillance System (BRFSS). Unfortunately, until recently its use for vision-related data has been limited. Prior to 2005, BRFSS has only included two vision-related questions, both a part of a secondary diabetes optional module. Beginning in 2005, due largely to the efforts of CDC’s Vision Health Initiative, a vision and eye health module – Vision Impairment and Access to Eye Care – became available. Over the past several years, Prevent Blindness America, in partnership with CDC and state governments, successfully engaged numerous states in this important epidemiological effort by convincing them of the need for such data in the development of successful vision preservation programs. In 2005, 4 of the 5 states running the module were PBA affiliated; in 2006, this number was 9 of 11; and in 2007, 8 of 10.

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Partnerships


The National Association of Chronic Disease Directors (NACCD)

Prevent Blindness America recognized the importance of engaging state public health systems in its efforts to advance vision preservation activities. Toward this end, a partnership was developed with the National Association of Chronic Disease Directors (NACDD), which led to a number of initiatives. As an initial effort, the NACDD partnership resulted in an abbreviated literature review on state-based vision and eye health efforts – Age-related Eye Diseases: An Emerging Challenge for Public Health Professionals . This was coupled with an assessment of the vision-related activities of seven states, which included surveys as well as site visits to meet with key players in each state’s public health network. The states included in this effort were Arizona, Arkansas, Florida, Georgia, Maine, New Mexico and Ohio. This process resulted in the publication of a document entitled Vision Problems in the U.S.: Recommendations for a State Public Health Response [PDF–195KB] . Among the findings of this assessment process were that most states had vision programs to some degree or another that were linked to their diabetes programs; there existed a few statewide councils; there was some Medicaid coverage for vision; and that rehabilitation agencies and Veterans Administration facilities generally addressed vision. It was also discovered that there existed little evidence of systematic coordinated planning; there were few community based services; data was generally not available on vision problems, and there was no integration of vision services outside of diabetes.

Following the release of this report, a working group was formed consisting of representatives of state public health agencies, CDC, and Prevent Blindness America and its affiliates, to recommend actions that would result in state-based comprehensive vision preservation programs. The working group met in the fall of 2005 to reach consensus on the key elements of this action plan. The resulting document, A Plan for the Development of State Based Vision Preservation Programs [PDF–5MB], serves as a summary of the working group’s deliberations. The report describes the current status of public health vision conservation; recommends increased adult vision preservation activities within state chronic disease programs; recommends increased program activity by Prevent Blindness America; emphasizes collaborative roles and activities for health departments, Prevent Blindness America, and other vision preservation organizations; and recommends that CDC identify comprehensive and coordinated strategies and priorities in eye health and vision preservation that can serve as the basis for collaborative initiatives. This last recommendation was addressed by CDC’S Vision Health Initiative in 2007 with the publication of its Improving the Nation’s Vision Health: A Coordinated Public Health Approach. Over the course of this partnership, both Prevent Blindness America and key members of NACDD recognized the value of an ongoing structure through which to advance vision and eye health into state public health systems. Therefore, in 2007, the organizations worked together to initiate a standing Vision and Eye Health Work Group of NACDD. It conducts its work through a number of sub-teams, which address the topics of communication, data, national and local partnerships, and primary care. This group continues to foster collaboration among state public health professionals, other state agencies, and non-governmental partners to expand and integrate programs to prevent vision loss.

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WISEWOMAN

Another important partnership was forged between Prevent Blindness North Carolina and that state’s WISEWOMAN initiative . There are 1,996,481 women in North Carolina over the age of 40 and 62,098 of these are estimated to have a visual impairment. Diseases and conditions such as diabetes and obesity impact both general health and eye health. An estimated 18,416 women over age 18 in North Carolina have diabetic retinopathy and 3,404 women over 40 have primary open angle glaucoma. Less than 50 percent of low-income seniors and only 60 percent of African-Americans age 40 and older receive services from an eye care professional on a regular basis; and of the adult seniors screened in rural eastern North Carolina in 2005, 70% were women.

Due to these alarming statistics, Prevent Blindness North Carolina decided to focus on this population with initial funding through this cooperative agreement. During their program development phase, collaboration began with the state’s WISEWOMAN initiative, a CDC-sponsored project that offers health interventions to underinsured women ages 40-65, many of whom are low income, uninsured or under-insured. While this program offered screenings for blood pressure, cholesterol and diabetes; provided intervention classes on diet, physical activity and smoking cessation; and offered medical referral and following; it did not include vision screenings.

After initial discussion, the two programs established a mechanism that would address this missing need. Prevent Blindness North Carolina refocused their energies on counties which were also served by WISEWOMAN; they added a series of risk assessment questions to the traditional vision screening program and made referrals to the WISEWOMAN program based on the results of the assessment. WISEWOMAN, in return, shared information on the Prevent Blindness vision screening initiatives with their county coordinators to ensure cross fertilization of each program. As a result of this collaboration, between 2005 and 2008, Prevent Blindness North Carolina screened a total of 5,318 adults in 13 counties served by WISEWOMAN. Of these, 3,615 were female, 1,082 were referred for follow-up eye care, and 890 were referred to WISEWOMAN for enrollment in their public health screening and education programs.
 

 

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Vision and Eye Health Education

Educating the general public and professionals on a variety of issues related to vision and eye health is an essential component of any public health program. Prevent Blindness America achieved this objective through its website, newsletter, and a series of public service announcements. Prevent Blindness America and its affiliates developed and delivered a number of state and national education symposia. These events increased the understanding of vision and eye health issues while creating state coalitions and other opportunities for collaboration. Public education and the process of bringing together multiple disciplines advanced a public health response to vision problems.
 

Over the past five years, such events have taken place in Georgia, Florida, Tennessee and Illinois; along with a national symposium focused on addressing issues related to the economic and other public health impact of vision problems in the United States.

  • In 2004, Prevent Blindness Georgia hosted a symposium entitled “The Aging Eye,” during which a number of presentations were delivered to the general public focusing on the four major age-related eye conditions – cataract, diabetic retinopathy, glaucoma and macular degeneration.
  • In 2005, “Florida’s Vision…Awaken to the Challenge,” was hosted by Prevent Blindness Florida to bring together the medical community, public health officials, educators, elected leaders, government representatives, and vocational and rehabilitation professionals.
  • Prevent Blindness Tennessee held a symposium in 2006 in collaboration with the Tennessee State Health Department. The event included speakers from the Tennessee Academy of Ophthalmology and the Tennessee Optometric Association to address topics of aging-eye disease and low vision.
  • Later in 2006, Prevent Blindness America joined with the Illinois Society for the Prevention of Blindness to host the “Illinois Vision Symposium: Understanding the Aging Eye.” Discussion topics included the four major aging eye diseases; public health and aging in Illinois; the social, emotional and mental health impact of vision impairment; and living with low vision.

In 2007, Prevent Blindness America hosted “The Impact of Vision Problems in the U.S.,” a national vision symposium held in Washington, DC to address issues primarily related to the economic cost of these problems to the overall U.S. economy. This event also served as an avenue for the release of The Economic Impact of Vision Problems: The Toll of Major Adult Eye Disorders, Visual Impairment and Blindness on the U.S. Economy [PDF–197KB]. This document combined outcomes from two studies to detail a total economic impact from adult eye disorders on the U.S. economy of $51.4 billion annually. This report continues to serve as a valuable resource when advocating for policy change or increased funding for vision and eye health research and programming.
 

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State-Based Projects:


Georgia
The aim of Prevent Blindness Georgia’s Adult Demonstration Project was to provide training for senior center staff and eye health education for their clients by offering eye exams onsite at senior centers. At the senior centers Prevent Blindness provided each client eye examinations to identify eye disease and begin treatment, while educating the client about the importance of regular eye exams. During this project, Prevent Blindness Georgia substantially enhanced professional education for health coordinators and expanded the number of eye exams and eyeglasses provided to seniors. The addition of vision clinics at senior centers across Georgia provided much needed eye exams. Perhaps more importantly they also educated health coordinators about aging eye diseases, how to best link clients to care, and what they can do to help save vision. During the first three years of this program, 48 individuals were trained as vision screeners and 46 clinics took place. As a result, 723 at-risk adults were given eye exams and 611 were referred for follow-up eye exams for aging eye diseases. This work made a profound difference improving the quality of life and saving sight for hundreds of at-risks adults. This innovative program demonstrated the importance of provider education and training to ensure quality vision care for all seniors.

Florida
Prevent Blindness Florida established its Healthy Vision Corner Program to offer vision education and screenings at Florida health department clinics. Through this initiative, they are able to provide a physical vision education area in select clinics throughout Hillsborough, Manatee, Orange, Pinellas, Polk, Orange and Sarasota counties. The clinics offer brochures, resource materials and monthly vision screenings. During the course of this project, a partnership was forged with the University of Central Florida’s and the University of South Florida’s Pre-Optometry Societies to volunteer at the screenings. The students were trained and certified as vision screeners and volunteer their time to assist with the screening events, which include a risk assessment, visual acuity test, visual field screening and, when necessary, referral to an eye care professional. If financial assistance is needed, Prevent Blindness Florida provides an eligibility packet and/or applications from partnering organizations who provide free exams and glasses. In addition to helping the public, this partnership provides a learning opportunity for the students and introduces them to volunteerism and public health. The Healthy Vision Corner Program has been well received by the clinics and their patient population. In 2008 alone, Prevent Blindness Florida served approximately 4,200 people through the Healthy Vision Corners. This was an increase of 20% over the previous year.
 

Ohio
In 2003, Prevent Blindness Ohio began collaborating with East Central Neighborhood Health Center (CNHC), as well as Access Health Columbus (AHC), to expand access to vision care and to direct resources to populations that are at greatest risk of not receiving needed vision care services. Prevent Blindness Ohio conducted a vision screening training course for all primary care physicians, nurses and medical assistants employed at the five CNHC health center sites. The vision screening training equipped clinicians to conduct vision screenings for all new patients, high-risk patients, and pediatric patients at least once per year. The training also served to introduce a standardized approach of referring patients to the Vision Clinic at the East Central Neighborhood Health Center. Over the first three years of this initiative, the results have been impressive. 324 adult care providers were trained and certified as vision screeners, 163 primary care providers were trained and certified, and 36,335 adult vision screenings were provided as a result.

Kentucky
The Kentucky Division of Prevent Blindness America received funding through this cooperative agreement for the past five years to screen, educate and provide follow-up vision care for adults in one of the most at-risk communities in this country — the Appalachian Region of Eastern Kentucky. Between 2003 and 2008, this program expanded its services from six counties to eleven counties, and partnered with local healthcare clinics to provide health education and vision screenings for acuity, glaucoma, diabetic retinopathy and age-related macular degeneration. During this time, thousands of individuals were screened, most for the first time in their adult lives. In 2008 alone, 1,350 individuals were screened, with a referral rate of approximately 34%.
 

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Expansion Efforts


In July 2008 Prevent Blindness America officially established its first two regional offices to support the program expansion and training efforts of the Chicago-based national office and to complement the existing outreach efforts of its affiliate network. A Director of Prevent Blindness America-Northeast was hired and based in Boston, Massachusetts, to serve a five state region, including Maine, Massachusetts, New Hampshire, Rhode Island and Vermont. A Director of Prevent Blindness America-Northwest was hired and based in Portland, Oregon, to serve the states of Idaho, Montana, Oregon, Washington and Wyoming. These regional offices not only serve as vision screening trainers and local Prevent Blindness resources, but they also have begun establishing themselves as a central knowledge base throughout their regions to ensure a coordination of vision and eye health services throughout their assigned states.

 

Integration Efforts

Primary Health Care

Over the course of this cooperative agreement, Prevent Blindness America and its affiliates have undertaken efforts to more effectively engage primary healthcare providers in the vision and eye health of their patients. To begin a national dialogue on the issue, Prevent Blindness America worked closely with CDC and the National Eye Health Education Program of the National Eye Institute to convene a workgroup to explore the challenges and opportunities related to vision and eye health in the primary care setting. In addition to those previously mentioned, participating organizations included the American Academy of Nurse Practitioners, the American Academy of Ophthalmology, the American Academy of Optometry, the American Academy of Physician Assistants, the American Optometric Association, the American Society of Ophthalmic Registered Nurses, the National Association of Community Health Centers and the Society of General Internal Medicine. Since the initial workgroup, Prevent Blindness America has enhanced its website through the addition of a Healthcare Professionals section of the site, and adding key resources targeting healthcare professionals. Another outcome of this workgroup has been the establishment of an ongoing primary care team within the Vision and Eye Health Work Group of NACDD.

The integration of vision efforts throughout state health departments has been a driving goal of this overall effort. As a resource to advance the mission of vision integration in state public health departments, Prevent Blindness America worked closely with its partners at CDC and NACDD to create a DVD to be used as a mailer to health departments, in presentations, or other communication venues. The video details the value of integration and establishes important integration concepts. To advance the practice of vision integration, in year five of the cooperative agreement, several small grants were provided to Prevent Blindness affiliates to further engage their states’ own health departments around these important issues.

 

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