The Assistive Devices Program (ADP)

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Professor of Optometry at the University of Waterloo
Nov 16 2010
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A novel program to support device-assisted vision rehabilitation in Ontario Canada

 

 

J. Graham Strong OD MSc

Professor, School of Optometry

Director, Centre for Sight Enhancement

University of Waterloo CANADA

 

Ann D Plotkin OD MSc

Head, Low Vision Services

Associate Director, Centre for Sight Enhancement

School of Optometry

University of Waterloo CANADA

 

Background

 

The Assistive Devices Program (ADP), which supports people with disabilities in Ontario Canada (population 13,134,4551), is administered by the Ontario Ministry of Health and Long-Term Care (Ministry). The primary objective of ADP is “to provide support and funding to Ontario residents with long-term physical disabilities to obtain personalized assistive devices that enable them to function more independently.” ADP covers over 8,000 separate pieces of equipment or supplies in the following categories:

  • prostheses
  • wheelchairs/mobility aids and specialized seating systems
  • enteral feeding supplies
  • monitors and test strips for insulin-dependent diabetics (through an agreement with the Canadian Diabetes Association)
  • insulin pumps and supplies for children
  • hearing aids
  • respiratory equipment
  • orthoses (braces, garments and pumps)
  • visual and communication aids
  • oxygen and oxygen delivery equipment, such as concentrators, cylinders, liquid systems and related supplies, such as masks and tubing.
In addition, grants are provided for ostomy supplies, breast prostheses and for needles and syringes for insulin-dependent seniors.

 

Although funding support differs somewhat across disability categories, the essential steps involved are similar. A client’s first exposure to ADP is often through a diagnosing physician (ophthalmologist or optometrist for visual aids category) who registers the individual with ADP. A follow-up rehabilitation assessment is conducted to determine the client’s needs and to prescribe the appropriate devices or supplies (ADP authorization). The client then selects a vendor from whom to purchase the prescribed device or supplies. For most devices, the client pays a portion of the equipment’s cost at the time of purchase, and the vendor who supplies the device bills the Ministry for the balance. The ADP contribution is the lesser of two amounts: 75% of the actual purchase price of a device, or an ADP-dictated maximum contribution toward a device. ADP eligibility is extended to all Ontario residents with valid Ontario Health Insurance coverage and who have a physical disability that has persisted for at least six months. The program further stipulates that equipment being funded must not be required exclusively for sports, work or school. ADP does not pay for equipment available under the Workplace Safety and Insurance Board or to Group “A” veterans for their pensioned benefits. There are specific eligibility criteria which apply to each device category. The total ADP expenditure for all device categories was $347 million2 in 2008/09. Of this expenditure, less than 2% of this amount was spent on visual aids3 (See Figure 1).

 

Figure 1

Figure 1.  Assistive Devices Program Expenditures by Device Categories, 2008/09 ($ Million)

Source of data: 2009 Annual Report of the Office of the Auditor General of Ontario

 

The visual aids benefits under ADP are significantly underexploited because most potential beneficiaries and their caregivers are unaware of the potential utility of device-assisted vision rehabilitation. From a service provider’s perspective, the bureaucracy and paperwork is ungainly and the requisite registration and authorization services are poorly remunerated under the Ontario Health Insurance Plan (OHIP).4

 

...the poorer-than-expected participation of patients and providers seems inevitable. With its deliberate focus on access to devices rather than access to services, the Assistive Devices Program would be particularly enticing for patients who were already seeking devices and for providers who were already providing them. The program would be of predictably less benefit to patients and providers who were not yet "plugged into" the rehabilitation system. In other words, the Assistive Devices Program did little to help visually impaired people who were not already being seen, or to help the providers who were not already seeing them.5


Visual Aids and ADP

 

ADP coverage for visual aids was introduced in the early eighties with coverage limited to Ontario youngsters and adolescents aged 16 years or younger. Over a relatively brief period, this coverage was extended to people of all ages. The breadth and range of ADP visual aids coverage is extensive, although the program has fallen far behind with respect to coverage of new device technologies (especially newer video-based devices such as portable CCTV systems, head or face worn video devices, GPS-based mobility devices, and print access devices). The program has also been criticised for failing to keep abreast of real market pricing of eligible devices (overpaying for computers and adaptations and underfunding for customized optical devices). Another concern has been the Ministry’s failure to update the program’s manual since 1997 to incorporate changes to ADP policies and procedures that have occurred over the ensuing decade. The following is a summary of eligible device inclusions and exclusions under the visual aids section of ADP in all of the approved device categories.6 These categorizations are significant because ADP funding guidelines preclude the purchase of duplicate devices or for two different devices having the same essential function. Accordingly, ADP will fund only one device per function, in each of the aids categories: optical, reading, writing, and orientation and mobility.

 

Equipment Covered

 

Optical Aids:

  • Magnifiers
  • Telescopes, Binoculars
  • Field Enhancement
  • Specialized Eyeglasses
  • Specialized Contact Lenses
  • Non-prescription Absorptive Filters
People with low vision are eligible for three different optical aids, based on the assumption that people may require different devices for near, mid-range and distant seeing activities. However, consumers may obtain up to three optical aids for use at any distance, provided that the devices are not identical, and provided that none are intended for the same seeing tasks. Within the optical aids category, limited ADP support is available to assist with the purchase of specialized spectacles and/or contact lenses for some ADP clients. The following spectacle lenses qualify for ADP funding:
  • Distance spectacle lenses and/or contact lenses having a spherical equivalent power that is greater in magnitude than +/-10.00 Dioptres.
  • Bifocal spectacle lenses with a bifocal addition that is greater than +4.00 Dioptres.
  • Selective transmission lenses (such as Corning CPF lenses) of any power (including plano lenses) which are prescribed as an assistive device.
  • Special aperture contact lenses, selective transmission contact lenses, or piggyback contact lenses.
Reading Aids
  • Variable Speed Tape Recorders/Daisy Player
  • Electro-optical Systems - includes Closed Circuit Television (CCTV) systems
  • Optical Character Recognition (OCR) Systems
ADP clients are eligible for only one high technology device in the Reading Aids category.

Writing Aids
  • Adapted Computer Systems with Sight Enhancement Specialized Peripherals (e.g. screen magnification, large monitors) and/or Sight Substitution Specialized Peripherals (e.g. speech synthesis)
  • Braille Keyboard
  • Braillers, Slate & Stylus
  • Braille Access Device
ADP clients are eligible for only one high technology device from the Writing Aids category. Sight substitution device users, however, are eligible for one low tech and one high tech writing aid.

Orientation and Mobility Aids
  • Standard Canes
Consumers are eligible for a standard long white cane.

Equipment Excluded
  • Optical items costing less than $20
  • Talking watches
  • Braille watches
  • Clocks
  • Calculators
  • Basic corrective (emmetropizing) lenses (equivalent power less than +/- 10.00D)
  • Surgically implanted (intraocular) lenses
  • Equipment or supplies required solely for educational, vocational or recreational purposes.
  • ADP is not mandated to cover the cost of special devices for people whose primary diagnosis is a learning disability.
An obvious problem with the “one device per function” funding constraint is the significant burden placed on the authorization assessment to provide prudent advice to consumers about which devices should be submitted for ADP funding support. A significant number of people opt for multiple devices for categorically similar seeing activities. They are best served when their ADP support is used toward the purchase of the most effective device (one that “works best” from amongst all of the devices that simply “work”) and the device that is the most costly to purchase. This problem has been addressed in the high technology portion of the ADP program through a “competitive enablement” approach to assessment.7 “Competitive enablement” is a demonstrably effective conceptual approach wherein “individual consumers evaluate the functional utility of competing device interventions while performing a series of self-identified problematic tasks of high functional relevance to the individuals themselves. Adherence to this approach lessens abandonment rates and produces significant impacts in both functional and psychosocial domains.”8

In order for consumers to make rational decisions with respect to assistive device selections, they need to experience, or at least understand, the relative merits of the competing devices that are available to assist them. This becomes difficult when there are multiple points of service, each with different capabilities and resources, and that are operationally disconnected from one another.

The following three elemental tiers have been identified in the ADP service delivery model:

  1. ADP Registration:  For ADP purposes, this service is performed by a “Prescriber” and refers to the physician or optometrist who clinically evaluates a client's level of visual functioning, thereby confirming her or his eligibility for obtaining ADP funding support to purchase or lease visual aids. It is the role of the prescriber (i.e., an optometrist or a physician - preferably an ophthalmologist) to ensure that the person's vision-related medical and surgical needs are being adequately addressed and managed, before any devices are authorized. The causal disorder is diagnosed, and its amenability to conventional medical, surgical or refractive treatment is verified. Anyone with valid Ontario Health coverage becomes eligible for ADP benefits under the Visual Aids Program if her or his visual functioning is diminished to the extent that she or he is unable to perform common, every day age-related visual tasks in spite of conventional medical, surgical and/or routine refractive interventions. Although ADP is responsive to evidence of functional low vision deficits, the general clinical eligibility benchmark is a reduction in visual acuity in the better-seeing eye with best correction to approximately 20/70 or less (with diminished vision function expected to persist at this level or worse for a period of six months or longer).

  2. ADP Authorization:  For ADP purposes, this service is performed by an “Authorizer” and refers to ADP-registered professionals (including Ophthalmologists, Optometrists, CNIB Vision Rehabilitation Workers, Orientation Mobility Instructors, and Specialist Teachers of the Blind) who authorize the purchase of specific ADP-approved visual aids based on information obtained from consumers and prescribers, who are guided by their own specialized knowledge of the most suitable devices for each client. This process involves an organized assessment to determine which specific visual aids are most appropriate for the individual client, given her or his specific visual needs and visual capabilities. In formulating the final ADP authorization, the authorizer typically considers the following factors:
    • Is the device eligible for ADP funding? Is it listed in the current ADP manual? Does it comply with ADP’s “one device per function” guidelines?
    • Has the device been authorized in accordance with ADP policies? Is the device being authorized by an ADP-approved authorizer for that device and has the authorizer personally conducted the assessment leading to the device authorization?
    • Is the intended use of the device consistent with ADP's mandate? Is it to be used for every day purposes in one's home?

    3. Authorizers must be aware of the range of ADP-approved devices that are available, and their own limitations for authorizing them. Referral to other authorizers is warranted whenever the appropriate devices are not available for assessment, or whenever the authorizer does not have ADP-approval to authorize the devices that are implicated by her or his assessment interactions with the client. Authorizers assume responsibility for ensuring proper assessment, training and evaluation of the clients' effective use of the devices being authorized.


  3. ADP Vending:  For ADP purposes, this service is performed by an “ADP Vendor” and refers to any business, from which an ADP client may obtain visual devices, and which is fully compliant with all of the conditions required for registration as an ADP vendor (as outlined in an ADP Vendor Agreement). Authorized devices may be purchased from any retail outlet having "registered vendor" status within the ADP program. Stock magnifiers, telescopes and binoculars can be obtained in this way. The vendor bills ADP based on the approved ADP price or grant. The vendor bills the client for the balance. The devices that are dispensed must conform exactly to the written specifications of the registered authorizer.
All first time applicants for ADP visual aids benefits must be seen in accordance with the three-tier service model. Clients accessing ADP for the second time or on any subsequent occasion can obtain devices in accordance with the two-tier delivery model, which consists of an ADP-registered authorizer and an ADP-registered vendor. The single tier delivery model, consisting of an ADP-registered authorizer/vendor or an ADP-registered vendor, may be appropriate for two different service scenarios: 
  • ADP-registered clients who obtain optical aids from ADP-registered optometrists or ophthalmologists.
  • Established ADP clients (who already have accessed the program on one or more occasions) may replace standard mobility canes, variable speed tape recorders, slates and styli, and braillers in direct interactions with ADP vendors (when replacement conforms to ADP replacement policy).
Device Replacement Policies

ADP support for replacing a device is generally provided any time on the recommendation of the prescriber or authorizer (as relevant to the equipment category) if a change in medical condition or growth/atrophy requires new equipment. Otherwise, ADP assists with the purchase of a replacement visual aid at the end of the ADP approved replacement period (approximately 5 years for most devices), but only when the original aid is no longer functioning properly. Replacement periods vary somewhat, depending upon the age of the client. Replacement periods are longer for older consumers as adults are expected to be more responsible in caring for and maintaining their equipment in functioning order. Visual aids are not automatically replaced when the normal replacement period has been reached. There must be a verifiable need to replace the visual aid, such as when it no longer meets the client's rehabilitation needs, or the device has deteriorated to a level that it jeopardizes the client's safety.

CCTV Devices and Adapted Computer Systems

ADP provides funding support towards the lease or purchase of equipment by individuals whose long-term functional disability precludes reading and/or writing without the use of specialized assistive devices. The applicant must have a definable need to use a reading or writing device on a regular basis, which is taken to mean an average of more than three to four times per week. Determination of use may be influenced by age, health, skill level, and degree of participation in the community. Applicants also must be able to communicate basic ideas using written, symbolic, sign language, or any other form of standard "person-to-person" communication. Specialized protocols have been implemented for obtaining ADP funding support for reading and writing aids (primarily high technology devices and CCTV systems). For the purposes of the ADP Visual Aids Program a reading aid is “any assistive device or system that can be used by a blind or visually impaired person to apprehend the meaning, significance, and substance of printed or written materials.”9 A writing aid is “any assistive device or system that can be used by a blind or visually impaired person to create letters, numbers, words, patterns, or symbols which can be shared with another person, or which can be stored and read later by the writer or someone else.”10 The nature of reading and writing aids will differ depending on the user’s level of vision impairment. Sight substitution technologies (speech and tactile displays) are commonly required by people with little or no functional vision. Sight enhancement technologies (magnified and/or visibility-enhanced displays) are commonly required by people who are vision impaired, but have retained some level of functional vision. The requisite ADP authorization services are provided at regional centres that are equipped with a suitably comprehensive array of CCTV and high tech systems to conduct assessments in accordance with “competitive enablement” protocols. The utility and effectiveness of these protocols have been validated by systematic outcomes research (functional status outcomes and psychosocial status measures) and by uncharacteristically low device abandonment rates of approximately 5%.1112

 

ADP Authorizer Profile

 

Lapointe (2006)13 reported that primary level low vision services are provided in Ontario by 182 optometrists and 23 ophthalmologists from across the province. However, these data are reported without stipulating what level of activity qualifies one to be considered a “service provider.” With this in mind, Strong (2007)14 analyzed ADP’s actual authorization data from January 1, 2005 to January 1, 2007 to discover the professional background, geographic distribution, and prescriptive profiles of vision professionals who authorized at least five or more devices over this two-year period. This was deemed to be a very modest threshold when ADP counts spectacles’ lenses and the frames that hold them as two separate authorizations. These data are described in Figures 2, 3, and 4.

 

Figure 2

Figure 2.  Professional designation of “active” ADP authorizers
(those who authorized five or more low technology low vision devices between January 1, 2005 and January 1, 2007). (From Strong 2007)

 

Figure 3

Figure 3.  Provincial distribution and professional designation of “active” ADP authorizers
(authorized five or more low technology low vision devices between January 1, 2005 and January 1, 2007. (From Strong 2007)


Figure 4

Figure 4.  Total number of devices authorized for ADP payment by participating professions
between January 1, 2005 and January 1, 2007. (From Strong 2007)

 

Remuneration for Low Vision Assessment

 

In 2008, the Ontario Ministry of Health and Long Term Care introduced new Ontario Health Insurance Plan payment codes for “vision rehabilitation assessments” that apply exclusively to ophthalmologists who provide these services.15 The fee structure describes payments of $240 for an “Initial vision rehabilitation assessment” and $120 for a “Follow-up vision rehabilitation assessment”. The requisite services are described as follows:

 

Initial vision rehabilitation assessment by an ophthalmologist of a patient with either low visual acuity16, visual field defect17, or significant oculomotor dysfunction18 subject to the conditions below.

This service is only payable when a minimum of four (4) of the following eight (8) listed components are rendered during the same visit:

  1. Cognitive assessment to determine capacity to cooperate with assessment and treatment.
  2. Assessment of residual visual function to include at least two of the following tests: visual acuity tested with ETDRS charts, macular perimetry, contrast sensitivity tested at 5 spatial frequencies and fixation instability.
  3. Assessment of eccentric preferred retinal loci.
  4. Assessment of near functional visual acuity with ETDRS charts.
  5. Assessment of reading skills. (For example, using MNRead or Colenbrander charts.)
  6. Prescribing of low vision devices aimed to improve residual visual function.
  7. Preparation of a vision rehabilitation plan and/or discussion of the plan with the patient.
  8. Supervised training of the patient, in accordance with recognized programs, for use of low vision devices and/or training for rehabilitation of skills dependent on vision.
Follow-up Vision Rehabilitation Assessment

This service is only payable when a minimum of three (3) of the eight (8) components listed above are rendered in the same visit.

 

The Ministry’s decision to cover only those people who receive vision rehabilitation services from ophthalmologists is disappointingly incompatible with the established patterns of assessment service. In addition, the specific basis for payment creates the prospect of payments for an array of clinical procedures that are unrelated to the low vision assessment protocols that are fundamental to ADP device authorizations.

 

Conclusion

 

The Assistive Devices Program provides a significant benefit for Ontario residents with vision loss. Failure to provide suitable remuneration for optometric low vision assessment services contributes significantly to the program’s underutilization by eligible beneficiaries. This is an important dissuader for recent graduates entering optometric practice.19 Another significant factor has been ignorance within the ophthalmological and optometric professions concerning the significant benefits of vision rehabilitation services and the importance of timely referrals for these services.

References and End Notes

 

  1. Based on adjusted 2006 Census population counts. Accessed on-line June 24, 2010 at http://www.statcan.gc.ca/daily-quotidien/100325/t100325a2-eng.htm
  2. Assistive Devices Program in 2009 Annual Report of the Office of the Auditor General of Ontario. Queen’s Printer for Ontario. Page 52-79. Accessed on-line at http://www.auditor.on.ca/en/reports_en/en09/2009AR_en_web_entire.pdf 
  3. The precise amount was not available because Visual Aids and Communication Aids were reported collectively.
  4. Strong JG (2001) Ontario Assistive Devices Program: A Managed Low Vision Care Network, in Vision Loss Rehabilitation: Service Delivery, Policy and Funding Massof and Lidoff eds. AFB Press 2001. pp 203-211.
  5. Ibid, pg 207.
  6. Assistive Devices Program Branch, Ontario Ministry of Health (1997) Visual Aids Manual: Section 1.0 Policy and Procedures, North York, Ontario
  7. Strong G, Jutai J, Plotkin A, Bevers P (2008) Competitive enablement: A consumer-oriented approach to device selection in device-assisted vision rehabilitation. (Ed.)  Mann WC. Aging, Disability and Independence: Selected Papers from the 4th International Conference on Aging, Disability and Independence (2008). University of Florida. pp175-195.
  8. Ibid pg 175
  9. Assistive Devices Program (ADP) Branch, Ontario Ministry of Health (1992) Reading and Writing Visual Aids Policy. September, 1992.  North York, Ontario (VA 1-17)
  10. Ibid
  11. Huber JG, Jutai JW, Strong JG, Plotkin AD (2008) Psychosocial Impact of Closed-Circuit Television (CCTV) Devices in Age-Related Macular Degeneration. Journal of Visual Impairment and Blindness 108(11):690-701.
  12. Strong G, Jutai JW, Bevers P, Hartley M, Plotkin A. (2003) The psychosocial impact of closed-circuit television (CCTV) low vision aids.  Visual Impairment Research, 5(3):179–190.
  13. Lapointe ML (2006) Services available to sight-impaired and legally blind patients in Ontario: the Ontario model Can J Ophthalmol 41:367–369.
  14. Strong JG (2007) Optometric co-management of partially cured ophthalmic patients. 18th annual Dr. Clair Bobier Lecture in Vision. University of Waterloo. Waterloo Ontario. June 8, 2007.
  15. Consultation and Visits: Ophthalmology A76 – A77 (October 2009). Accessed on-line June 25, 2010 at http://www.health.gov.on.ca/english/providers/program/ohip/sob/physserv/a_consul.pdf
  16. Ibid. Defined as best corrected visual acuity of 20/50 (6/15) or less in the better eye and not amenable to further medical and/or surgical treatment.
  17. Ibid. Defined as splitting of fixation, scotomata, quadranopic or hemianopic field defects not amenable to further medical and/or surgical treatment.
  18. Ibid. Defined as nerve palsy or nystagmus resulting in low visual acuity or visual field defects as defined and not amenable to further medical and/or surgical treatment
  19. Wittich W, Strong G, Renaud J, and Southall K. (2007) How to make Low Vision “sexy”: A starting point for interdisciplinary student recruitment, Re:View, 38(4):157-163.

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Dec 9 2010
rmassof's picture

Effect of device coverage on device dispensing

 by Robert W. Massof, Ph.D.

This is a very valuable reference that provides important data to those of us interested in making the case for Medicare coverage of vision assistive equipment (VAE).  I am interested in learning if the existence of ADP coverage of VAE has affected the dispensing of VAE in Ontario, for better or worse.  One might expect dispensing to diminish because the availability of coverage would discourage self-pay, while the documentation burden and eligibility constraints would discourage filing for ADP coverage.  Considering the fact that optometrists practicing low vision outnumber ophthalmologists practicing low vision  by as much as 8 to 1, but optometrists are not eligible to authorize ADP coverage claims for their patients, how do optometrists' patients acquire devices?  Do they self-pay, or does the patient have to be referred to an ophthalmologist for authorization? 

Robert W. Massof, PhD Johns Hopkins Wilmer Eye Institute

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