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Service Delivery Innovation Profile

Free Eye Care for Low-Income, Uninsured Children Combined With Vision Education for School Staff Improves Eye Care Knowledge and Academic Performance

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Between 1998 and 2008, Palmetto Health’s Vision Health Initiative partnered with local Walmart vision centers and area optometrists to provide free, comprehensive eye exams and glasses to low-income, uninsured children enrolled in kindergarten through grade 12. Education and training was also provided to school nurses, teachers, and counselors on detecting vision problems in students. The initiative enhanced access to needed vision care for a population with no other means of accessing such services. It also increased knowledge of eye health and proper eye care and helped to improve children’s attitudes and academic performance. The program ended in 2008 after South Carolina expanded insurance coverage to the target population being served.

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on program usage along with comparisons of pre- and post-implementation data from a parent survey on knowledge about eye care, academic performance, and attitudes.
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Developing Organizations

Palmetto Health
Columbia, SCend do

Date First Implemented

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Patient Population

Vulnerable Populations > Children; Impoverished; Medically uninsured; Insurance Status > Uninsuredend pp

Problem Addressed

Thousands of children suffer from undetected vision problems that can have a significant impact on quality of life and, left untreated, lead to permanent vision loss and delayed development. While most schools provide students with vision screenings, children from low-income families without vision insurance often lack the means to access the followup care they need.
  • A prevalent concern, particularly among low-income children: Roughly one in four school-age children—representing more than 12.1 million individuals—have some type of vision problem.1 Children whose families live on an income below the Federal poverty level (FPL) are nearly twice as likely to be visually impaired as those from families with incomes above 200 percent of FPL, yet they are much less likely to have seen an eye-care provider during the past year (17 percent versus 22.7 percent).2
  • Lack of insurance a barrier: For families lacking insurance, routine eye exams and corrective lenses represent a costly, often unaffordable out-of-pocket expense. Data from the National Health Interview Survey found that uninsured children aged 6 to 17 are less likely to receive eye care than are children with private or public insurance.3

What They Did

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Description of the Innovative Activity

Between 1998 and 2008, Palmetto Health’s Vision Health Initiative partnered with local Walmart vision centers and area optometrists to provide free, comprehensive eye exams and glasses to low-income, uninsured children enrolled in kindergarten through grade 12, along with education and training for school nurses, teachers, and counselors on detecting vision problems in students. Key program elements included the following:
  • Target population: The Vision Health Initiative provided services to children in grades kindergarten through 12 who live at or below 200 percent of FPL and who lack vision insurance. Children had to reside in one of four South Carolina counties (Richland, Lexington, Pickens, or Fairfield). Although designed specifically to meet the needs of low-income children whose families do not qualify for coverage under Medicaid, the program also served low-income children with private health insurance plans that did not cover eye care.
  • Free, comprehensive eye care: Each eligible child received a free comprehensive eye exam and up to two pairs of glasses each year. While optometrists at local Walmart vision centers provided the services, Palmetto Health paid for 100 percent of the costs. The screening and care process worked as follows:
    • Patient screening and referral: School nurses from all school districts within the program’s four-county service area referred eligible students to the program when routine school vision screenings uncovered potential vision problems. In addition, parents who suspect their child might have a vision problem contacted the program directly.
    • Program intake and scheduling: A representative from Palmetto Health’s existing call center handled calls from referred children or their parents, screening each child for eligibility. With the child or parent still on the line, the representative scheduled an eye exam with a participating optometrist. The call center mailed the patient a reminder letter confirming the date, time, and location of the appointment.
    • Free services at local Walmart centers: Patients received program services, including eye exams and glasses, at one of four partnering Walmart vision centers. Bilingual staff were available in at least one of these centers for Spanish-speaking patients.
    • Followup services: Each patient received an annual reminder to schedule an eye exam.
  • Replacement glasses for children with Medicaid: From 1998 through 2006, the program provided children covered under Medicaid with one free replacement pair of glasses. (Medicaid allows only one pair of glasses per year, making replacements difficult to obtain.) School nurses referred children on Medicaid with a valid prescription to the program. This service ended in 2006 due to budget cuts.
  • Vision health education: The program collaborated with an optometrist to provide free training and education sessions to school nurses, teachers, and guidance counselors on detecting vision problems in children. Sessions took place at the schools, covering proper use of the eye chart screening tool, strategies for observing and questioning students about vision problems, and warning signs that signal potential vision problems in students based on classroom behavior and performance. Up to eight sessions were held each year based on the needs and availability of school personnel.

Context of the Innovation

The Vision Health Initiative is operated out of the Office of Community Services at Palmetto Health, South Carolina’s largest nonprofit health system. In the late 1990s, Dr. Lonnie Randolph, a local optometrist and member of Palmetto Health’s Community Outreach Advisory Task Force, noticed that many low-income children in South Carolina did not receive necessary vision care, as their families did not qualify for Medicaid and they could not afford to purchase insurance or pay for eye exams and corrective lenses on their own. In 1998, Palmetto Health launched the Vision Health Initiative to address this problem.

Did It Work?

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Post-implementation data suggest that the program enhanced access to eye care for a population that had no other means of accessing such services, while pre- and post-implementation data suggest that it increased knowledge and awareness about eye health and proper eye care and helped improve children’s attitudes and academic performance.
  • Facilitated access to services: From the program’s inception in 1998 to September 30, 2008, the Vision Health Initiative provided participants with 4,698 eye exams, 3,549 pairs of new glasses, and 435 pairs of replacement glasses to children covered under Medicaid. In the absence of the program, most participants would likely have been unable to access these services.
  • Increased knowledge, awareness: A pre- and post-intervention survey mailed to over 2,500 parents showed that 89 percent of families reported being knowledgeable about proper eye care and the need for regular vision exams after receiving program services, compared to 78 percent reporting such knowledge before the program. Most parents (78 percent) reported having a greater awareness of eye health as a result of receiving program services.
  • Improved academic performance and attitude: Most parents reported that the program was instrumental in improving their child’s academic performance (86 percent) and overall attitude and confidence (78 percent). Among children receiving glasses, the percentage receiving grades in the D-to-F range fell from 40 percent before the program to 10 percent after implementation.

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on program usage along with comparisons of pre- and post-implementation data from a parent survey on knowledge about eye care, academic performance, and attitudes.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Conducting research: Palmetto Health researched the state of children’s vision health in South Carolina, confirming the existence of a gap in coverage among low-income, uninsured children. They also assessed existing community health programs to verify that no one else provided eye care services to this population.
  • Assembling planning committee: Palmetto Health’s Office of Community Services assembled a committee of school nurses, social workers, and optometrists from within the target service area to provide guidance in planning the initiative.
  • Getting buy-in from health system: Once an outline for the program was established, the committee presented its plan and supporting data to Palmetto Health’s Community Health Committee, which approved the program and agreed to include funding as a line item in the health system’s budget.
  • Recruiting partners and refining model: Palmetto Health staff met with area optometrists to invite them to participate in the program. Initially, Palmetto partnered with independent optometrists who provided services from community health centers within the service area. When it became clear that patients found this model confusing, Palmetto Health began to look for more stable and sustainable sites. In 2004, the program partnered with the corporate office of Walmart, securing agreement to provide all eye exams and corrective lenses though four local Walmart Vision Centers. Palmetto established contracts both with Walmart and with the individual optometrists operating out of the centers.
  • Building publicity: Program representatives conducted outreach at various sites and events throughout the community, including meetings of local Parent Teacher Organizations and area civic groups, church gatherings, school nurse cluster meetings, and back-to-school events. The program also ran a number of radio advertisements and partnered with the South Carolina Commission for the Blind to garner support and raise awareness of the program and the problem it addresses.
  • Terminating program after coverage expanded: In 2008, South Carolina’s State Children's Health Insurance Program program expanded, providing coverage to families who previously did not have access to public insurance. Because its target population now had vision health coverage, the program ended on September 30, 2008.

Resources Used and Skills Needed

  • Staffing: In the early stages, one full-time community advocate staffed the program, traveling between health centers and helping parents fill out paperwork. Once the initiative partnered with Walmart, the service delivery process became streamlined, requiring only about 4 hours per week for one staff member within Palmetto Health’s Office of Community Services. In addition, Palmetto Health’s call center representatives spent some time handling program intake and scheduling over the phone as part of their regular duties.
  • Costs: The program cost roughly $100,000 per year.
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Funding Sources

Palmetto Health
Program funding was included as a line item within Palmetto Health's overall budget.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Ensure strong relations with school nurses and counselors: Keep lines of communication open with nurses and counselors so they feel comfortable and confident referring children to the program.
  • Partner with a group of providers: Establish partnerships with agencies or provider groups that can offer a turnkey service to patients. Emphasize to potential partners that they will be reimbursed for services provided and will be part of an initiative designed to provide free services to low-income children.

Sustaining This Innovation

  • Survey parents: Continually survey parents of children served by the program to elicit their feedback and identify opportunities for improvement. Responding to parent questions and concerns helps in establishing a reputation for quality service.
  • Nurture partnerships: Ensure that partnering optometrists find participating in the program to be a smooth process. Invite and respond to their feedback on the service delivery process.
  • Market on an ongoing basis: Promote the program widely in order to maintain awareness in the community. Such publicity can lead to higher utilization and sustained support.

More Information

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Contact the Innovator

Tiffany Sullivan
Director of Community Outreach Programs
Palmetto Health
P.O. Box 2266
Columbia, SC 29202
Phone: (803) 296-3071

References/Related Articles

Palmetto Health’s Web site is available at:


1 Prevent Blindness America. Our Vision for Children's Vision [Web site]. 2008. Available at: (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 Centers for Disease Control and Prevention. Visual impairment and use of eye-care services and protective eyewear among children—United States, 2002. MMRW Morb Mortal Wkly Rep. 2005 May 6;54(17):425-9. Available at:
3 Kemper AR, Bruckman D, Freed GL. Receipt of specialty eye care by children. Ambul Pediatr. 2003 Sep-Oct;3(5):270-4. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 25, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 16, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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