Orientation & Mobility (O&M) Services for People with Moderate Low Vision

Background

In North America vision loss (low vision) is strongly associated with aging. Over the age of 80, 1 in 5 have some significant reduction of vision, primarily from age related macular degeneration (AMD).¹ The elderly have a variety of co-morbidities related to the aging process including but not limited to arthritis, or other joint pain, and poor stamina due to heart disease. From the perspective of safety, visually impaired seniors describe a high number of falls^2-4 and a fear of falling.^5-7 Falls amongst the elderly has been identified by the Center for Disease Control (CDC) as a major health issue with a national public relations campaign going on right now to educate Americans about falls, the importance of fall prevention, and methods by which to reduce the risk of falls in homes and elsewhere.⁸

Orientation & Mobility (O&M) services for the blind and severely visually impaired

O&M instruction as a professional service, began shortly after world war II. The first instructors came from the VA sponsored corrective therapy program.  Eventually they branched off into their own profession known as peripatologists.  For the past 45 years years they have been referred to as Orientation and Mobility Instructors (O&M), with those being certified known as COMS (certified Orientation and Mobility Specialists).  This instructional program may include techniques and skills for crossing the street safely, identifying and walking on stairs and changes in elevation, modifications to the environment to enhance visual ability and personal safety, and the use of the long cane to detect objects in the path and to identify the location of stairs and curbs. As a general statement the teaching of these skills to the blind and severely visually impaired is understood to be of value, which is demonstrated through the number of people who have increased independence and safety because of having received this instruction.

Who needs O&M services? When should O&M services be available?

We know what happens to mobility for a person who is severely visually impaired and/or totally blind - they cannot walk safely and benefit from instruction. What we do not know is when during the early process of losing vision that mobility problems first occur and what O&M instruction, if any, could be of benefit. Working within the context of legal definitions for when this service is currently provided, government standards use 20/200 or worse visual acuity in the better seeing eye with standard eyeglasses as the definition of legal blindness, with anyone meeting this standard being eligible for O&M services. Definitions of low vision vary with the most commonly accepted standard being 20/70 – 20/200 visual acuity. Elderly persons with vision loss in this category are not generally provided with O&M instruction. The rationale for the exclusion has a variety of elements: self-reported problems usually deal with reading and near point work; in most States it is legal to drive with 20/70 and in several States you can legally drive a car with up to 20/200 visual acuity. If a person is safe to drive a car, why would their vision loss result in problems when walking? As evidenced by the paucity of services for older adults and the lack of coverage of O&M instruction by 3rd party payers such as Medicare, there seems to be little support for the idea that low vision patients with 20/70-20/200 visual acuity need O&M instruction. An informal conversation with eye care specialists would show that many eye care specialists don’t hear mobility concerns from these patients nor do the physicians see problems with these patients as they ambulate around their clinics.

Are O&M instructors knowledgeable about the needs and do they have the skills to offer O&M services to this population?

If O&M services were made available to people with mild or moderate vision loss we are not sure that O&M instructors would know what to teach and we think there may be a need for continuing education to serve the needs of this population. There are a number of published studies to support the claim that people with mild or moderate visual impairment (20/70-20/200), are at high risk of morbidity and mortality from falls and from poor health associated with self-imposed limitations on physical activity.^4,6 There also are numerous studies showing that low vision subjects have mobility problems, especially related to changing illumination, drop-offs, transitions in surface texture, and crossing streets.^9,10 An O&M instructor looking at the list of problems would recognize them as being similar to the list provided by people with severe low vision. The instructional program would involve the use of non-optical approaches to managing illumination (wrap around sunlenses, hats/visors), proper footwear for walking, and the use of the long cane to detect changes in elevation (curbs, stairs) and changes in surface texture.

Are the techniques and instructional strategies that are taught to the severely visually impaired generalizable to persons with mild or moderate vision loss? Could someone who legally drives a car need O&M instruction? Could they need cane instruction? Would they accept the cane or reject it because it is a symbol of blindness?

To answer these question the Lions Vision Research and Rehabilitation Center at the Johns Hopkins Wilmer Eye Institute has organized a collaborative low vision research network (LOVRNET) made up of low vision rehabilitation services representing all geographic regions of the United States. LOVRNET presently is collecting pilot data in preparation for a major clinical trial, the Low Vision Collaborative Orientation and Mobility Study (LOVCOMS). The objectives of the proposed program of research are to determine if O&M instruction improves mobility function in older adults with mild to moderate low vision, and in the long term if O&M instruction facilitates better physical and mental health and fewer injuries. This study, which currently is being planned with the support of the National Eye Institute, will test the hypothesis that Medicare coverage of orientation and mobility services for patients with moderate (20/70-20/200 acuity level) low vision will increase their safety when walking and traveling in their home community.

In addition to the scientific merit of this research, we need to be concerned about future funding for services if the results show a positive effect from O&M instruction. Because the majority of persons with low vision are older adults, it is necessary to simulate the Medicare model of funding and management in the study. According to current Medicare policy, a maximum of 15 hours of (OT, PT and or Speech and Language Pathology) service can be provided at a payable rate of approximately $125 per hour of direct instruction, depending upon your regional Medicare carrier. The COMS will be able to provide direct instruction that will be individualized to the needs and goals of each participant. Currently,  15 LOVRNET low vision centers and 30 certified O&M specialists (COMS), representing the geographic region of each of the 15 low vision centers (2 instructors per center), have made a commitment to participate in the study. The clinical centers will recruit 2800 patients over 3.5 years. From the 2800 patients we expect that 1300 will meet the criteria for services that will be provided by the COMS. The results of this study could lead to changes in Medicare law and/or coverage policy as well as private party insurance reimbursement.

We recognize that O&M for this group of patients may not be offered through the usual organizational structure of blind rehabilitation agencies.  Since these patients are typically seen in eye clinics it will be necessary for O&M to become familiar with the health care system, documentation of services, billing codes, and the myriad rules and regulations that cover the services that will be offered.  The importance of writing goals and objectives using language that follows Medicare guidelines will need to be stressed and perhaps taught through programs of continuing education.

The planning phase of LOVCOMS is still in progress.  It is my hope that the posting of this information will generate responses from interested parties.   I invite anyone reading this who has access to a low vision clinic and/or is a COMS to contact me since we are actively recruiting low vision clinics and COMS to share their ideas and to participate in the research program.

1. Congdon N, O’Colmain B, Klaver CC, Klein R, Munoz B, Friedman DS, Kempen J, Taylor HR, Mitchell P, et al. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol 2004;122:477-485.
2. Ivers RQ, Cumming RG, Mitchell P, Attebo K. Visual impairment and falls in older adults: The blue Mountains Eye Study. J Amer Geriat Soc 1998;46:58-64.
3. Abdelhafiz AH, Austin CA. Visual factors should be assessed in older people presenting with falls or hip fracture. Age and Ageing 2003;32:26-30.
4. Klein BE, Moss SE, Klein R, Lee KE, Cruickshanks KJ. Associations of visual function with physical outcomes and limitations 5 years later in an older population: The Beaver Dam Eye Study. Ophthalmology 2003;110:644-650.
5. Tinetti ME, Mendes de-Leon CF, Doucette JT, Baker DI. Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. J Gerontol 1994;49:M140-M147.
6. Arfen CL, Lach HW, Birge SJ, Miller JP. The prevalence and correlates of fear of falling in elderly persons living in the community. Am J Public Health 1994;84:565-570.
7. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling and restriction of mobility in elders. Age Ageing 1997;26:189-193.
8.  http://www.cdc.gov/homeandrecreationalsafety/falls/index.html
9. Turano KA, Massof RW, Quigley HA. A self-assessment instrument designed for measuring independent mobility in RP patients: Generalizability to glaucoma patients. Invest Ophthalmol Vis Sci 2002;43:2874-2881.
10. Smith, A. J., De l’Aune, W., & Geruschat, D. R. (1992).  Low vision mobility problems, perceptions of O&M specialists and persons with low vision.   J Vis Impair and Blind:86: 58-62.