eCare Community Monitoring Service

The eCare Community Monitoring Service supports the safe transfer and provision of sustainable care in the community for patients requiring ongoing monitoring of their eye condition.

Our eCare Community Monitonring Service supports the safe transfer and provision of sustainable care in the community for patients requiring ongoing monitoring, enabling hospital eye services to treat patients requiring high end specialist care. This enables the finite number of consultant ophthalmologists are used effectively and cost efficiencies across the local healthcare economy are realised. Unlike other community follow-up services, our model works within a strict clinical governance framework and every case/patient is reviewed by a consultant ophthalmologist.

The service provides the quality framework to assess and manage glaucoma patients in the community under the supervision of a consultant ophthalmologist. Through the implementation of our service, local healthcare economies will realise a number of benefits including:

  • More effective use of clinical resource Improvements in service quality
  • Value for money
  • Reduced waiting times
  • Community Glaucoma Monitoring Service | Evolutio Care Innovations Limited
  • Improved appropriateness of care (right care, right place, right time)
  • Provision of high quality, patient centric care
  • Implementation of an electronic shared care record
  • Convenient and accessible care closer to home
  • Introduction and utilisation of innovative technologies
  • Virtual OCT clinics and home monitoring apps for smartphones and tablets
  • Integrated working between secondary care and community service clinicians

List Validation

Often a barrier to realising the benefits of community follow-up services can be the time to reach full utilisation. To support the eye department in identifying appropriate patients for the service, we have the technical, IG and clinical capabilities to review the glaucoma list records, clinically grade and prioritise by risk. This process will provide two key benefits:

Current Position

To provide the trust a reconciled list of patients staying within the hospital eye department, graded by risk, priority and next follow-up date.

Patient Transfer

Ensuring a seamless and efficient handover of the patients to be seen in the community follow-up service and development of a shared electronic medical record for integrated care with the eye department.

Through this approach, we are able to maximise the number of patients that will be seen in the community from day one, ensuring higher patient satisfaction and value for money for the local healthcare economy.



Where a secondary care consultant has determined that a patient is suitable and has set the appropriate timeframe and intervals for monitoring, our integrated systems ensure that there are robust mechanisms in place for the booking of initial appointments and the call and recall of patients for long term monitoring.

At the first appointment, patients are given a full Primary Assessment Service (PAS) examination and the following additional information (if not previously collected) and investigations are recommended:

  • Demographics, history and symptoms
  • Anterior segment examination
  • Full threshold visual fields
  • GAT Contact Tonometry
  • Dilated Binocular Indirect Posterior segment examination
  • Retinal Imaging

Where a patient is deviating from target pressures set by the consultant ophthalmologist or presents with changes in symptoms outside the thresholds of the pathway, the patient will be referred to secondary care through a predefined pathway coordinated with the local eye department. We will integrate our pathway protocols with the local eye hospital to ensure rapid escalation of any patients requiring acute care.

Shared Care and Patient Empowerment

Through the inclusion of consultant ophthalmologists within our eCare community clinics, we work within a ‘shared care model’ where optometrists undertake diagnostic screening, where necessary, and consultant ophthalmologists provide analysis of test results in real-time via our integrated telemedicine platform, with access via desktop, smart-phones and tablets.

Self-management and shared decision making are fundamental to our service model as evidence suggests that patients who play a central role in their care experience will see both physical and psychological benefits.

We embed self- management programmes, information, education, advice and support across the entire patient pathway with all healthcare professionals able to deliver and advise on self-management tools.

We believe in patient centered care, where patients are empowered to take responsibility in managing their own health, working with our clinicians to develop their own sustainable and effective treatment plans. We adopt 5 key principles of patient centered care to ensure that the services we deliver involve and benefit the patient, providing them with the responsibility and tools to manage their condition. These principles are:


Choice and Empowerment

Access and Support

Information and patient involvement

These principles provide greater patient empowerment, responsibility and optimal clinical usage through the prioritisation of patients’ needs and experience in determining how their care is delivered.

We offer a multi-disciplinary service that utilises a bespoke shared electronic medical record and OCT telemedicine to serve as a mechanism to ensure the safe assessment and ongoing management of patients in a setting that is easily accessible and convenient.

The service is led by consultant ophthalmologists working with a team of appropriately qualified clinical practitioners to ensure a high level of clinical delivery, supervision and leadership. This proposal supports both national and strategic objectives of providing care closer to home, delivering evidence based pathways and supporting patient choice through innovative working and provision of cost-effective alternatives to secondary care.


Implementation and mobilisation

We bring extensive experience of mobilising a range of community services. Our experience gives us an in-depth understanding of the challenges and risks that are associated with both planning and implementing a local community service. Our plans therefore include the development of robust relationships with secondary care providers, optometrists and the local GP practices.

We are experienced at supporting the transition from incumbent to new service providers and ensuring that patients are transitioned seamlessly during a change in service provision. With the transfer of medical records, we have developed a highly efficient administrative operation to risk profile any case load handed over, highlighting potential ‘at risk’ patients and seamlessly transfer these for follow-up scheduling within the evolutio monitoring system.

Our approach is to start early, mobilise quickly and fully utilise our knowledge of providers and existing relationships with stakeholders. We can act quickly to invest resources in the areas that need it most, ensuring timely delivery of key milestones.

  • Identify local estate and clinic locations
  • Recruit and equip (if required)
  • Establish if there is a need to open own corporate clinic
  • Identify key stakeholders
  • Develop key pathways with secondary care
  • Deliver the communications strategy across providers
  • Service commencement

Our approach is to start early, mobilise quickly and fully utilise our knowledge of providers and existing relationships with stakeholders. We can act quickly to invest resources in the areas that need it most, ensuring timely delivery of key milestones.

If you would like to know more about our Community Monitoring Service please call us on

0203 780 7860 or email


We can also provide you with an individual CCG impact assessment detailing how the service can positively impact your specific locality. Phone or email and one of our team will be happy to discuss options.