In this episode of the Purpose in Practice podcast, ACU’s Jennifer Dix and Rick Brown speak with Dr. Kristin White, Director of Optometry at Health Care Partners of South Carolina and a member of ACU’s Vision Services Committee. Hear Dr. White share her optometry journey, how eye health provides clues to overall health, strategies for starting a vision services program at health centers, and more.

Full Transcript

Kristin White: My name’s Kristin White. I’m an optometrist. I work at a rural community health center in a part of Northern California where I work is called MACT Health Board, which is M A C T. It stands for Mariposa, Amador, Calaveras, and Tuolumne. And those are the four main counties where we serve. So our health center actually has five locations and expanding. We have one main location for optometry and then one satellite location. So our health center’s a little bit unique because we are actually an FQHC with tribal affiliation. So we do have Indian Health Service funding and we also see about 30% of our patients are Native American, and that makes our health center kind of unique compared to some others that I’ve worked at.

Jennifer Dix: Why is eye health and vision care important to someone’s overall health?

White: It’s so interesting really the ways that the eye allows us to see things that are going on in the rest of the body. So one thing I love to tell my patients is that the eye is the only part of the body where you can look in and actually see what the blood vessels are doing. In any other area of the body, you would need some sort of invasive surgery. And so diseases like diabetes and hypertension are two of the big ones that really can cause even very early changes to the shape of those blood vessels. So even before we see vision threatening damage to the vision, we can see these early changes that might look like a hardening or a thickening of the arteries, or it may look like the veins becoming more tortuous or wavy. And that indicates to us that the blood flow isn’t flowing properly for some reason.

White: And so a lot of times people will come to us to have their eyes checked thinking, oh, I need glasses, which they may. And oftentimes our patients haven’t had any sort of medical care in a number of years, sometimes decades. And so when they come to us in this kind of non-threatening environment of, oh, I’m just going to get some glasses, and then we dilate their eyes and assess the health, and we realize that there may be other things going on that they actually do really need to get connected to a primary care provider. And so oftentimes optometry ends up being this entry point into the healthcare system. So whether it’s diabetes or high blood pressure or the optic nerve inside the eye actually is a direct extension of the brain. And so there are conditions like multiple sclerosis or even brain tumors that can cause swelling or paleness or lack of blood flow to the optic nerve that we can see that can indicate some really serious systemic conditions.

Dix: That is fascinating and that’s something that I was unaware of the fact that you could learn so much about the human body through the eye. So that’s really interesting.

White: Yeah, I think most people aren’t aware of it because why would you be, you don’t think about it.

Dix: So, what are the unique healthcare needs and eye health needs really specifically of your particular patient population?

White: I would say that Native American communities as a whole tend to be more prone to certain inflammatory conditions of the eye. So that’s particularly called a uveitis. And so that’s one thing that we see a fair amount of based on our population here. Also being in a rural setting, we work with a lot of patients who work outside and they work with animals and they grind metal and they’re working on their ranches and things. So oftentimes it’s eye injuries too, whether it’s metal getting in the eye that we need to remove or an injury from caring for a farm animal or maybe even somebody came in because they had gotten kicked in the head by a horse. These things that growing up in the Northeast and practicing and living in Boston for quite a long time prior to being out here were not the reasons people would come into my office there.

Dix: Why do you think individuals who live in medically underserved areas often lack access to adequate vision care? And maybe talk about what some of the barriers are that those people may experience.

White: I think there’s a number of them. I think one big one ends up being transportation. So a lot of times our patients will travel one to two hours each way just to come see us. I’d say that’s the first one. And then having a ride, having money for gas. We’re in California where a gas is like five or $6 a gallon depending on the month, and that’s significant to have to drive four hours and pay for all that gas and this and that. A lot of our patients are on fixed income, so that makes it a strain for sure. But I think another reason is simply not knowing what coverage you might have. So up until two years ago, California Medicaid, which is called Medi-Cal, did not cover glasses for adults. And so many people would feel, well, if I can’t get glasses, what’s the point of getting my eyes checked?

White: Not knowing that connection to overall systemic health and this and that. And we often as humans need some motivating factor. And if the reason to go to the eye doctors is because you can’t see and then you feel like you’re not going to be able to afford glasses, then you may not go out of your way to get your eyes checked. So I think that’s a lot of it. And then even once someone does have coverage and can get to a location, I think also just having access to providers that accept their insurance. So as I mentioned, the majority of our patients are on Medicaid, and before we opened five and a half years ago, there was only one other Medicaid provider for the two counties where we serve. And as soon as we started seeing Medicaid patients, the private office that was seeing them kind of as a community service type thing stopped, they stopped seeing them.

White: So we’re the only providers in the two counties, and that’s hard. That’s hard when there’s just not a lot of people taking their insurance to be able to get seen. And so sometimes people will go to maybe a Stanton Optical if they happen to be in a city, maybe they’re going to Costco, so they’ll either get their eyes checked at Costco, which is fine, or Staton Optical, which people have been mentioning is like a video consult. So the doctor’s on a screen and they’ve expressed to not feeling like they’re getting really the complete picture. So yeah, I think it’s really multifactorial why people in rural settings are not getting the care they need.

Dix: What is needed to improve access to vision care for people who live in under-resourced communities?

White: Well, I feel like because community health centers are really the main medical hub for underserved areas, and the last statistics I had seen were that only about a quarter of health centers were offering vision services. I think that health centers providing onsite vision services or optometry services for their patients is really a crucial place to start. That’s the place that makes the most sense in terms of private practices as a whole are not going to all of a sudden start seeing Medicaid. That’s not how their practices are really set up just in terms of the reimbursements and things being so different at a health center. And health centers really can provide that whole person care that a lot of these people need, as I was mentioning earlier, that they might come in because they think they need glasses, but they have a lot of other systemic health conditions that need to be addressed. And so if you were just practicing out by yourself and not having somewhere else, you can connect this person to, whether it’s with primary care medicine or behavioral health services or dental services, they would still be going without the rest of their needs.

Dix: How can we advance health equity for patients living in rural areas?

White: Yeah, that’s a great question. I would say first is access, and then I would say even once access is there, because even for example, when we opened five and a half years ago, we still are seeing so many brand new patients that, oh, I didn’t know you guys were here. And so I really think spreading the word by whatever means is helpful in your community. Whether that’s going to be more newspaper ads or I was talking with a health center recently who’s in a pretty rural part of Alaska and out there radio ads were really effective in getting the word out, whereas most parts of the continental U.S. radio ads are, I don’t think of that as being the first form of communication that people are going to be looking into. So I think knowing how to reach people in your community, letting them know why vision health and eye health is so crucial and the connection to their overall health, I really think patients value the recommendations of their primary care physician. And so especially if their primary care physician is at the community health center and then that provider is recommending that they get their eyes checked and they can get their eyes checked also at the community health center, that they’re a lot more likely to do that, whereas if the doctor says, oh, by the way, have you gotten your eyes checked? You have diabetes, I said, well, where am I supposed to do that? And then another year, another year, another year go by that that hasn’t happened.

Dix: So do you have any examples of how your particular health center gets the word out about your practice?

White: Yeah, so when we first started, there was a lot of newspaper ads and flyers that would go out. I went into all of the schools in the county and did there. So that brought in a lot of patients, just families not knowing that there was now somewhere they could take their kids. Currently we’re just doing more internal marketing, so spreading the word amongst our five or six health center locations through the medical department to really try and bring patients to the care that they need.

Dix: What got you interested in health centers and working in that environment?

White: Yeah, I think a couple of things. So even before I went to optometry school, during undergrad, I had been doing a lot of volunteer work, Habitat for Humanity and different international mission trips kind of a thing. And I was on a Dominican Republic tour, I think it was my senior year of college, and I’m pushing this wheelbarrow of rocks as we’re building this wall. And I realized this is not my skill. I want a skill that I can travel anywhere with and building walls and pushing wheelbarrows of rocks is not my skill. And I was also in senior year trying to figure out what I’m going to do with my life beyond college and this and that. And my dad was an optometrist, and so I had been working with him but had really only seen optometry as private practice at that point. And so actually when I had gotten back from that trip and was working then working with him over the summer, he had recently gotten connected with Pearle Vision, which is a Luxottica organization, and they have their big nonprofit, which is called OneSight, which does domestic and international eye clinics.

White: And so that was the first time that I put two and two together that optometry could be more than a private practice and optometry could be a skill that could allow me to travel anywhere and provide a service. So I decided that optometry was then going to be my skill. And then when in optometry school, so I went to New England College of Optometry in Boston, and NECO has had a long, long longstanding history of providing care within community health centers. So they actually just celebrated their 50th year of being in health centers, which is really unique because as I mentioned earlier, most health centers throughout the country don’t have optometry. And because of NECO, the whole Boston area, most health centers do have optometry services. So going to school there from our first year of being in school, you get a lot of exposure to working within community health centers.

White: And so by doing that, I was able to realize or able to really feel like I was serving without necessarily having to travel internationally, although I do still like to do a lot of international eye. And so yeah, I would say that my undergrad experience and then my experience with NECO has definitely encouraged me on the community health path. And then I did a residency within community health optometry. I worked at that health center for an additional year, and then I worked with an Indian health facility out in New Mexico and then moved out to California where then I helped open up the eye clinic where I currently am.

Rick Brown: We often hear so much about FQHCs and FQHC lookalikes, sometimes struggling to find resources to open comprehensive health and vision care programs. I’m wondering just how did that come about at map?

White: Yeah, so my husband is also an optometrist, and so we had actually moved out to California. We for a brief time, were working at a private practice out here, and one of our patients at the practice was a public health nurse with MACT. And they got to talking, she was actually seeing my husband and he was saying we had just come from working with Indian Health Services and she said, oh, well our health center is an Indian Health Service affiliate. We’ve been wanting to have optometry for years and years and we just don’t know how. We didn’t have an optometrist to help get that program started. Would you be interested in talking to our CEO? And so she actually just set up a meeting for us and lo and behold, they were kind of at a good place. They had just been doing a renovation to a building, which half of it they knew they were going to make into a dental facility. And the other half, they didn’t have really firm plans for it. They wanted it to be some form of a specialty. They thought maybe they would have a cardiologist rotate through weekly or just sort of bring people in, but there was nothing, it was all very loosey-goosey. There was nothing firmly set as to what the other half of the building was going to be. So we met them. This building didn’t even have walls in it, and three months later we were working there and developing a clinic. I think that’s definitely unusual for how quickly our situation happened. I don’t know that it’s necessarily able to be replicated across the board with that swift amount timeline, but in our case, they were ready and we were ready. So it was kind of right place, right time.

Brown: Is there any advice that you might share with FQHCs or FQHC lookalikes who are interested in starting their own optometric services?

White: Yeah, absolutely. I would first check out the ACU’s webinars that we’ve done recently partnering with National Association of Community Health Centers because we have lots of resources there on how to get started. So maybe you guys can link to some of those in the notes, I think would be useful. If you’re coming from the health center perspective and wanting to start and unsure, I would reach out to local optometrists because you never know who might be interested in making a career change. A lot of times younger optometrists are practicing in commercial settings because they think that that might be the only way for them to afford to pay off their loans. But actually what I’m finding across the board with health centers is that the salaries are really competitive and between qualifying for public service loan forgiveness programs and some health centers are even offering loan repayment programs for their optometrists, there’s certainly ways for younger graduates or younger doctors as well to afford to work in that type of setting.

White: So I would start by reaching out to some local doctors. You can do an assessment of the needs of your health center as well. So depending on the size of the health center, would you need a full-time doctor? Is that what your clinic could support? Looking at some of those numbers and things, which we talk more about in some of those other webinars, I think that’s a really great place to start. And if you’re an optometrist and you’re wanting to work in a health center, but maybe the health center that’s near you doesn’t offer optometry, I would just reach out and start a conversation with them. We’re actually going to be moving to South Carolina in a month, and we sent a few letters. We wanted to move closer to family, and we sent letters to multiple health centers that were in that area, none of which included optometry.

White: And one got back to us and said, oh, hey, we’re sorry we don’t offer optometry, but otherwise we don’t have a job for you basically. And then I said, oh, actually, I’d love to talk with you about starting that department. And I said, oh, well, we misunderstood your email or your letter. Yeah, let’s set up a call. And so we set up a call and that was, I don’t know, about six months ago and we’re going to be starting the department there in January. So I think just opening that door to that conversation, I feel like a lot of health centers right now do kind of have it in the back of their mind that optometry is a valuable service for their patients and they just might not know, well, who’s going to do it? Who’s going to get started? We have all these other projects going on within our health center, how do we get going? And I think finding a connection with an optometrist is really going to be the way to push that forward because they can help what equipment you’re going to need and assess your patient base and things like that. And it can be really helpful to hire that doctor on just as a consultant in the beginning and until you’re ready to actually start seeing patients so they can really help you create the department.

Brown: One thing that you mentioned before was that people just often don’t think about vision care in certain ways. And I wonder if there’s one thing that you could share or that you’d like people to know about eye health and vision care that they may not, what would that one thing be?

White: I guess that our eye health is really directly connected to our overall health, and so even if you don’t need glasses, or even if you don’t think you need glasses, that having your eyes checked every one to two years just in the same way you should be having a physical exam, even if you feel fine and getting your blood work done and getting your teeth cleaned and all these other preventative things that we do think about, optometry really is a lot more than assessing a need for glasses and it’s directly connected to so much of our overall health. I definitely want to give a shout out to all optometrists out there that practicing in a community health center setting is rewarding, is challenging, is to me the best form of practicing optometry. I really like being able to provide this integrated care and connecting to other medical departments that are within the health center, and I just really feel like you get to serve a patient base who needs your care every single day without having to leave your community to do that.