LOW VISION Services, A Global Right Setting the Standards in Europe - PowerPoint Presentation

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LOW VISION Services, A Global Right Setting the Standards in Europe15-17 June 2018WHO International Standards for Vision RehabilitationDr. Filippo Amore

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This document is the outcome of a consultative process to elaborate international standards on vision rehabilitation. The process, which began in 2014, culminated in the International Consensus Conference on Vision rehabilitation, Rome (Italy) 9 – 12 December 2015. It was organized by the World Health Organization and supported by the Italian National Reference Centre for Services and Research for the Prevention of Blindness and Rehabilitation of the Visually Impaired, a WHO Collaborating Centre

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WHO is a specialised agency of the United Nations, leading the health sectorWHO provides policy advice and technical assistance to its 194 Member States, using published and practical evidence as the basis for its informed advice to MoHWHO leads a large number of global or regional initiatives for health, and is in charge to frame the post-2015 Development GoalsUniversal Health Access is the global theme from WHO for its Member States, and is the theme for the 2014-2019 eye care global plan… and it includes visual rehabilitationWHO and its Member States

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Universal Health Coverage (UHC) is the goal that all people obtain the health services they need without risking financial hardship from unaffordable out-of-pocket payments.It involves coverage with good health services, from health promotion to prevention, treatment, rehabilitation and palliation, as well as coverage with a form of financial risk protection.A third feature is universality since the coverage should be for everyoneUniversal Health Coverage and Access

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UHC is attained when people actually obtain the health service they need and benefit from financial risk protectionAccess is the opportunity or ability to do both these things. Hence, universal health coverage is not possible without universal access, but the two are not the sameThe three dimensions of the Access  Physical accessibilityFinancial affordability AcceptabilityUniversal Access

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Services are integrated and focused on the needs of people and communitiesCare is provided in the most appropriate setting Well-trained and motivated health workers Right

balance between out- and in-patient care

S

trengthening the coordination of care

Quality people-centered integrated care

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Sustainable Development GoalsServices are integrated and focused on the needs of people and communities

Care is provided in the most appropriate

setting

Well-trained and motivated health workers

Right balance between out- and in-patient

care

S

trengthening

the coordination of

care

Quality people-centered integrated care

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Why an International Consensus Conference on low vision rehabilitation?

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Universal Eye Health – Global Action Plan 2014-2019The aims of the plan are the prevention of the visual impairment and visual rehabilitationFor the first time the plan explicitly refers to visual rehabilitation as essential component of eye care

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The VISIONA world in which nobody is needlessly visually impaired, where those with unavoidable vision loss can achieve their full potential, and where there is universal access to comprehensive eye care servicesThe GOALSTo reduce avoidable visual impairment as a global public health problem and to secure access to rehabilitation services for the visually impaired The PURPOSETo achieve the goal by improving access to comprehensive eye care services that are integrated into health systems

Universal Eye Health – Global Action Plan 2014-2019

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Cross-cutting principles and approachesUniversal access and equityHuman rightsEvidence-based practiceLife course approachEmpowerment of people with blindness and visual impairment

Universal Eye Health – Global Action Plan 2014-2019

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Objective 1 addresses the need for generating evidence on the magnitude and causes of visual impairment and eye care services and uses it to advocate greater political and financial commitment by Member States to eye healthObjective 2 encourages the development and implementation of integrated national eye health policies, plans and programmes to enhance universal eye health with activities in line with WHO’s Framework for Action for strengthening health systems to improve health outcomesObjective 3 addresses multisectoral engagement and effective partnerships to strengthen eye health

There are 3 indicators

(the prevalence and cause of VI, the number of eye care personnel, cataract surgery) at the goal and purpose levels to measure progress at national

level

Universal Eye Health – Global Action Plan 2014-2019

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OBJECTIVE 2Action 4Proposed inputs from Member States Inputs from WHO Secretariat Proposed inputs from international partners

Provide comprehensive and equitable eye care services at primary, and secondary and tertiary levels.

Provide

and/or coordinate universal access to comprehensive and equitable eye care services,

including rehabilitation services for the visually impaired and blind.

 

Establish eye care quality standards and norms

Provide existing WHO tools and technical support

to Member States.

Develop quality norms and standards for services

Advocate on the importance of comprehensive and equitable eye care services. 

Provide eye care services, including rehabilitation services

in line with national policies and plans

through national coordination mechanisms. 

Monitor, evaluate and report on service provided in line with national policies and plans through national coordination mechanisms.

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Minimum standard for rehabilitationWhy step-wise?"One fit all" is rarely a feasible approach for WHO Member States, resulting in neglecting intervention as perceived unrealistic for the development level of the population or of the health system. Step-wise quality?At all level quality should not be compromised, but a careful selection of content of the rehabilitation offer can make it feasible (and accessible) to a wider number of people in need.Is step-wise only for rehabilitation?No. All health interventions are modelled to be feasible in the largest number of member states according to their development level.Is not trading quality but a modulation of the approach to health service provision

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In 2010, the WHO estimated285 million people around the world were living with visual impairment39 million of whom were blind, with most cases affecting people aged 50 years or older and predominantly resulting from preventable and curable chronic and genetic diseasesDefining International Rehabilitation Standards

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Low vision rehabilitation services are only accessible to around 15 per cent of the people around the world who need themDefining International Rehabilitation Standards

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Definition of Visual Impairment in ChildrenAn estimated 19 million children below age 15 are visually impaired. 12 million children are visually impaired due to refractive errors, a condition that could be easily diagnosed and corrected. 1.4 million are irreversibly blind for the rest of their lives and need visual rehabilitation interventions for a full psychological and personal development. 

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there is no internationally agreed definition on what professional vision rehabilitation is, no verified model there is no agreement on what are the core, fundamental, necessary standards of care to be offered there are no internationally agreed variables to be used in evaluation, no definition of acceptable costs, no indicators to monitor progresses many approaches exist, mainly in rich countries, many models and systems, definitions and outcomesno evaluation systematically done to verify the appropriate use of resources.What was missing

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A process was launched to produce a set of standards for visual rehabilitationThese will serve as guidance and support for governments in all aspects of the establishment of visual habilitation and rehabilitation services at all levels of health careDefining International Rehabilitation Standards

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In May 2013, the National Centre for the Prevention of Blindness and Rehabilitation of the Visually Impaired has been officially designated by the World Health Organization as a Collaborating Centre for Visual Rehabilitation and Blindness PreventionDefining International Rehabilitation

Standards

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REHABILITATION

WHO-International Consensus Conference (ICC)

Visual Rehabilitation Standards

General Objectives defined by the WHO for the National Centre

Overview

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Templates have been developedBearing in mind the WHO levels of Care: primary, secondary and tertiaryUsing a different approach for adults and childrenIdentifying the different areas of the rehabilitative interventionEach LEVEL and AREA have been graphically represented in terms of coverage and complexity Overview

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Primary level

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Secondary level

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Tertiary level

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StrengthsWeaknessesOpportunitiesThreatsWHO African Region WHO Region of the Americas WHO South-East Asia Region WHO European Region WHO Eastern Mediterranean Region WHO Western Pacific Region

SWOT Analysis

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The DEFINITION WHAT type of services HOW these services could /should be provided By WHOM they should be carried outAt WHAT level (Where) of the health care system We have 3 levels of services; for the PRIMARY and SECONDARY it has been agreed to identify MINIMUM STANDARDS AND MINIMUM PLUS; the differentiation between adults and children has been reinforced

Defining International

Rehabilitation

Standards

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Vision Rehabilitation « Integrated services for vision rehabilitation, provided by trained workforce that assist patients to achieve their goals despite irreversible vision loss. » (Preliminary Meeting July 2015)OR Integrated services/training and devices that assist patients to achieve their goals despite vision loss Blind RehabilitationServices/training/devices that assist individuals without vision to achieve their goals

Definitions

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The approach to the person who has a vision impairment and undertakes a rehabilitation program should be multidisciplinary and centered on the person and not clinically-focusedThe rehabilitative intervention should be tiered on the basis of the individual goals and risksIt is recommended that a rehabilitation supervisor is assigned to every patient, to coordinate the multidisciplinary approach and to update patient’s recordsIs necessary to have collaboration, cooperation and communication between all professionals involved in the process of vision rehabilitation and between workers at different levels of the vision rehabilitation processAgreement on the

following points

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The lack of data at country level on need for vision rehabilitation requires that the collection of data occurs from primary level; the tertiary level will collect the data and analyze them to identify if needs of the population are satisfied In children, the habilitative/rehabilitative intervention should start as early as possibleAgreement on the following points

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It is appropriate to revise the definition of a person with low vision as defined by the WHO in in following way:“May eligible to vision rehabilitation patients with low vision as defined by WHO/PBL/93.27, and generally patients with bilateral visual defects, of troubles of visual cognition interfering with daily life” It is appropriate to speak of vision rehabilitation and no more of visual rehabilitation, since the vision should be considered as a multiple function: a function of perception, exploration, cognition and regulation, and vision rehabilitation should therefore be addressed through a multidisciplinary approach, tailored to the specific needs of the individualAgreement on the following

points

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The overlapping of competencies across the health system cadres makes it appropriate to speak of skills and not of professional roles, especially at the primary level, regardless of the economic settingIt is necessary therefore to develop curricula for operators of vision rehabilitation (eye care workers, health care workers and medical studies)Agreement on the following points

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It is recommended to use the WHO-TARSS (Tool for Assessment of Rehabilitation and Support Services) as the tool to provide the information needed to assess the current rehabilitation needs and gaps in service provision and to monitor access to the same following the recommended process of the Universal Health CoverageAgreement on the following points

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PrimarySecondaryTertiaryScreening of AcuityRefer for Comprehensive Eye ExamGoals and RisksNon OpticalSighted Guide

Data Collection

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PrimarySecondaryTertiaryScreening of AcuityRefer for Comprehensive Eye ExamGoals and RisksNon OpticalSighted Guide

Data Collection

Support Groups

Refraction

Devices/cell phone/

Training

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PrimarySecondaryTertiaryScreening of AcuityVisual Function/RefractionRefer for Comprehensive Eye ExamFunctional Vision – how vision is used eg readingGoals and RisksGoals/Risks/Co-morbiditiesNon Optical

Non Optical/

Optical

Sighted GuideO & M

Psychosocial Support

Training

Data Collection

Data

Collection

Support Groups

Refraction

Devices/cell phone/

Training

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PrimarySecondaryTertiaryScreening of AcuityVisual Function/RefractionRefer for Comprehensive Eye ExamFunctional Vision – how vision is used eg. readingGoals and RisksGoals/Risks/Co-morbidities

Non OpticalNon

Optical/Optical

Sighted GuideO

& MPsychosocial Support

Training

Data Collection

Data

Collection

Support Groups

Refraction

Devices/cell phone/

Training

Braille

Assistive Technology

Vocational Counseling

Home visits

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PrimarySecondaryTertiaryScreening of AcuityVisual Function/RefractionVisual Function ++Refer for Comprehensive Eye ExamFunctional Vision – how vision is used eg readingFunctional Vision ++Goals and RisksGoals/Risks/Co-morbidities

Goal/Risks/Case management

Non OpticalNon

Optical/OpticalNon/Optical/Adv Electronic

Sighted GuideO & M

O & M/ GPS ++

Psychosocial Support

Psychological

Support

Training

Training

- Advanced

Braille

Vocational Counseling

Home visits

Data Collection

Data

Collection

Data

Collection

Support Groups

Refraction

Devices/cell phone/

Training

Braille

Assistive Technology

Vocational Counseling

Home visits

Training

Research

Data collection

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Development ageEarly intervention and accessible education. All education and teaching much then be made accessible, if not, the child is not able to participate in society, to fulfil their rights as a human being. Those with visual impairment warrant identification to ensure all education is perceivable, comprehensible, and learnable. This means an individual approach matched to abilities of each childA life course approach - The goal of interventions for children with visual impairment should be “to get it right for every child”

Empowerment of

child (and family) with visual impairment starting at the earliest age

, so they gain social acceptance, access to life, and dignity as any other person, as well as support the development of advocacy skills for the child and family

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Differences between Adults and Children Adults: may have a background of normal visual experiences. Children: developing functions and concepts based on impaired vision Different expertise are needed according to age even for   childrenDefinition of Visual Impairment in Children

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Tiered levels of services: primary, secondary, tertiaryAppropriate intensity of rehabilitation Basic low vision services available Model of service

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Visual Impairment in ChildrenIt is possible to learn without vision but it is crucial to have a clear profile of competences of a child in order to give the right support and use the best methods, according to the child’s needs, to make possible a good neurodevelopment and cognitive level. Visual impairment and hearing impairment are often hidden disabilities. They are not obvious as cerebral palsy, or other physical challenges are. Children’s services are different than adult services and require different approach according to child’s ageIdentification and referral for diagnostic evaluation begin at the primary level. Children with visual impairment may be referred to

secondary or tertiary level for

diagnosis and habilitation planning but it is expected that these services are to be

provided in part at the primary or community level where the child lives.

Minimum standard widely diffuse

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Essential Number of people served/percentage of access to vision (re)habilitation servicesNumber of equipped facilities establishedNumber and type of human resources trainedNumber and type of devices prescribed, trained and dispensedNumber of referrals received at all three levelsQuality of life impact assessment:

Education

Employment

Psychosocial well-being

Optional

Number of people with low vision assessed:

New cases

Follow up cases

Disaggregated by demographics

Co-morbidities

Number of follow up consultations per patient

Number of trained staff retained

Number and types of awareness-raising programs developed and undertaken

Level of satisfaction

Indicators

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ConclusionThe standard-setting process has resulted in a comprehensive set of standards for vision habilitation/rehabilitation at the three levels of care, which can be applied in developed and developing settings alikeThese standards comprise a comprehensive, multidisciplinary approach to eye care and rehabilitationEfforts are placed not only on diagnosis, treatment and rehabilitation care, but also on the importance of advocacy, awareness raising among families and communities, and ensuring adequate training for all individuals working with people with visual impairment, whether at the clinical or rehabilitation areas or within the wider context

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The standards aim: to help governments in providing a quality of care and support for persons with visual impairment and for the neuro-development of the children;to maximize their participation; to enhance quality of life and well-being

and optimize their potential within society

, thus reducing the burden of comorbidities

Conclusion

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We agreed on the lack of training to vision rehabilitation methods worldwide, even in high income settings. A lot of work has to be done to introduce vision rehabilitation teaching in the curricula of eye care workers, health care workers, and Medical studies worldwideWe have to train primary health care personnel to detect, refer, and follow-up persons with visual impairment. This is especially true in low income settingsIn the handling of persons with visual impairment, the family and the low vision peers should play a critical role, especially in counseling, advocacy and motivationTools for detection of the Level of satisfaction

Challenges

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Thank youEBU office

6 rue Gager-Gabillot75015 Paris

FranceTel: 00 33 1 47 05 38 20

E-mail: ebu@euroblind.org

Personal details

Dr. Filippo Amore, Ophthalmologist, Director of the Italian National Center for Vision Rehabilitation of the Visually Impaired-WHO Collaborating Center

Tel

: 0039 334 633 9561

E-mail:

f.amore@iapb.it