Fact Sheet for General Practitioner and Practice Nurses Health assessments for people with intellectual disabilities: opportunities for better health

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1 Fact Sheet for General Practitioner and Practice Nurses Health assessments for people with intellectual disabilities: opportunities for better health This document is designed to facilitate the use of the Annual Health Assessment MBS items to facilitate comprehensive healthcare of people with intellectual disabilities. People with intellectual disabilities live with complex health and social needs that are often unrecognised or inadequately treated and their consequent poor health impacts on both length and quality of life. When compared to the general population they have: 25 X the rate of epilepsy X the rate of visual impairment 11X the rate of hearing impairment 7 X the rate of dental and oral disease 4 X the rate of mental illness 3X the rate of obesity 2 X the rate of hospitalisation They also have v increased risk of nutritional and swallowing difficulties; gastro-oesophageal reflux disease & constipation; thyroid dysfunction and osteoporosis. v reduced rates of screening (Pap testing, mammography, testicular and prostate) v reduced rates of immunisation v less exercise and access to other health promotion interventions v Fewer economic and social resources Medicare funded HEALTH ASSESSMENTS (including those for People with Intellectual Disabilities) enable comprehensive assessments of health and social needs to be performed. TIME FRAMES and FEES (Aug 2011): MBS Item 701: Brief < 30 minutes. Fee $56 MBS Item 703: Standard > 30 minutes < 45 minutes. Fee $ MBS Item 705: Long > 45 minutes < 60 minutes. Fee $ MBS Item 707: Prolonged > 60 minutes. Fee $ Health Assessments may lead to a GP MANAGEMENT PLAN (MBS Item 721) and TEAM CARE ARRANGEMENTS (MBS Item 723) Note: The Comprehensive Health Assessment Program (CHAP) is used by Disability Support Workers providing care to people with intellectual disabilities in staffed accommodation funded by DHS across Victoria. It is a useful tool to facilitate the gathering of the information required for a Health Assessment.

2 PRIOR TO HEALTH ASSESSMENT. General Practice identifies a person with an intellectual disability requiring annual Health Assessment (new patient or practice recall system) contact made (by Practice Nurse when available) to patient s home to arrange appointment. OR Disability Support Worker (DSW) or family member identifies the need. The person making the appointment should state that it is for a Health Assessment to ensure an appointment of appropriate length is booked. When the patient lives in DHS funded accommodation, the DSW completes a Comprehensive Health Assessment Profile (CHAP) in collaboration with patient & family. The CHAP is a useful tool to facilitate gathering past and current health information, as are other medical and patient held records. HEALTH ASSESSMENT. (This can be performed over one or two appointments.) Practice Nurse (PN) (when available) sees patient with DSW and/or family records health information in patient file, reviews and clarifies items in Part 1 of CHAP when available, and performs and records examination items as previously arranged with GP (height, weight, BP, urinalysis etc). GP sees patient & reviews history, performs examination and formulates an Action Plan to address the patient s health issues claiming Health Assessment MBS items 703, 705 or 707. Provides Report of Health Assessment, including Action Plan, to patient, family and/or DSW as appropriate AFTER HEALTH ASSESSMENT. When indicated GP prepares General Practice Management Plan (GPMP) MBS item 721 and including health promotion and disease prevention interventions. Provides copy to patient, family and/or DSW as appropriate. When indicated GP completes Team Care Arrangements (TCA) MBS item 723 to refer to other health professionals as required. Provides copy to patient, family and/or DSW as appropriate. DSW ensures items in Health Assessment Report/Action Plan, GPMP and TCA are actioned. GP reviews patient with results of investigations, referrals etc and formulates new Action Plan as required to be implemented by patient with support of DSW. PN ensures all items in Health Assessment Report/Action Plan, GPMP and TCA have been completed and that an automatic recall has been entered in the Practice management software to ensure those supporting the patient are notified when the Health Assessment is next due.

3 Resources for further information A Guide to better Primary Healthcare for People with intellectual disabilities Healthcare Guidelines for Adults with Developmental Disabilities: The Centre for Developmental Disability Health Victoria MBS information: Health Assessments for People with an Intellectual Disability GPMP and TCA Comprehensive Health Assessment Program (CHAP) data/assets/file/0019/228106/health_care_policy_att_12_chap_ brochure.pdf Pap Tests: The Plain Facts Accessing Mental Health Services for People with Intellectual Disabilities

4 Annual Health Assessments in General Practice ~ examples in practice ~ The following examples of practices using Medicare Health Assessments are based on interviews with General Practitioners and Practice Nurses who have successfully implemented these MBS items in their practice. Practice nurses can really help with Health Assessments. General Practice A identifies patients with an intellectual disability on the GP software system. The Practice Nurse organises appointments for the annual Health Assessment. Disability Support Workers complete the Comprehensive Health Assessment Profile (CHAP) prior to the appointment so all relevant information is available at the time of the consultation. When the patient and Disability Support Workers arrive, the Practice Nurse completes the documentation for the Health Assessment within the Medical Software system; the GP reviews it during the consultation and completes a report of the Health Assessment and a copy is provided to the patient/carers. Disability Workers, in conjunction with the PN and GP, support the patient to be as actively involved in the consultation as possible. Thorough, comprehensive and up to date documentation before, during and after the consultation is extremely important because of the number of people often involved in the care of the person with the disability; this may include the patient, family, multiple Disability Support Workers, GP, PN and other health professionals and agencies. Health issues, including disease prevention and health promotion activities, are followed up in subsequent appointments. Women are offered screening for breast and cervical cancer and their need for contraception is assessed. Team Care Arrangements (TCA) are organised as needed, enabling patients to access other health professionals with costs partially covered by Medicare. The PN organises for automatic annual reminders to be sent to people with an intellectual disability for their next annual Health Assessment. Annual Health Assessments get easier and quicker - as you get to know the patients The practice population for General Practice B includes thirty people with an intellectual disabilities living in six group homes. The GP finds the CHAP provides a useful proforma for collecting information and for an Action Plan format for the Report of the Health Assessment. The GP reports that the first time he completes a Health Assessment for a new patient it takes over an hour (MBS Items 705 or 707). Subsequent health assessments tend to be shorter. The assessment includes updating medication charts and following up on known health issues. Disability Support Workers complete the CHAP prior to the consultation. This may include searching for information in archived records to ensure previous diagnoses and responses to medication are recorded. Staff may be asked to organise blood tests in advance so they can be reviewed at the time of the Health Assessment. Staff are given a copy of the Health Assessment Report/Action Plan so they know what tests and referrals are required.

5 Congenital cataracts, Vitamin D deficiency, hearing impairment (sometimes related to ear wax), reduced bone mineral density have all been detected through the Health Assessment. Medication review has resulted in reduction or cessation of some medications. In one house the GP noticed that all residents had put on weight and a referral to a Dietitian was made. The referral resulted in an improvement in diet and an increase in exercise for the residents, with subsequent weight reduction and general improvement in health and fitness. The GPs advises colleagues Health Assessments get quicker and easier as you get to know the patients and do subsequent reviews. CHAP guides you to do the Assessment just follow the prompts. They are really worth doing you tend to pick up quite a few issues that need addressing. Health Assessments help me better understand my patients issues The population of solo General Practice C includes twenty people with intellectual disabilities and complex psychiatric and mental health issues who live in a Supported Residential Services. The GP conducts one annual review each fortnight, as well as addressing acute issues as they arise. He finds most reviews take just over an hour (MBS item 707). An optometrist and an audiologist screen the residents once a year. Women with intellectual disabilities are referred to a female GP nearby for breast screens and pap tests if they prefer a female GP for these procedures. Although locums are employed at times, the GP prefers to do all Health Assessments himself as he feels this assists him understand each patient s health and social issues. People who have intellectual disability have many disadvantages over others in relation to health care...and they put more trust in us than many of our other patients In General Practice D a regionally based GP completes about 100 annual health reviews for people with an intellectual disability each year using the (CHAP). He conducts the annual health reviews over two sessions and claims MBS item 707 for a prolonged session. His Practice Nurse provides immunisation sessions for seasonal influenza and other adult vaccinations. The Disability Support Worker completes the first section of CHAP, in conjunction with the patient, and brings the completed CHAP to the appointment. Documented observations of behaviour change are important information and may indicate the patient is in distress, discomfort or pain. The GP reviews the CHAP, completes the history, performs an examination and fills in the CHAP s second section. He updates medications and vaccinations on his Medical software. Pathology tests are ordered and referrals are made, including those for vision and hearing testing. Women are referred to Breast Screen Victoria for mammography. At the second consultation the GP reviews the results of pathology and referrals and works with the patient and Disability Support Worker to design an Action Plan. The Action Plan is detailed and clearly documented as staff turnover at the patient s home means that items in the Action Plan may be misunderstood or overlooked. Health Assessments have identified low Vitamin D, haemochromatosis, breast cancer, hypertension and many cases of inactivity and obesity. The GP advises his colleagues: People with intellectual disability have many disadvantages in relation to health care. they may be unable to describe how they feel, or recognise that what they feel is abnormal

6 staff changes lead to a lack of intimate knowledge of people s normal behaviour including simple things as appetite and activity levels. they are at increased risk of obesity, diabetes, hypothyroidism, Vitamin D deficiency, hyperlipidaemia, GORD, cardiorespiratory disease, UTI and other infections I m sure I could add to the list! It is extremely satisfying to look after their health and developing a relationship with them. They put more trust in us than other patient. The annual health review pushes GPs to check beyond the acute presentation In General Practice E the GP reported that she at first found the Health Assessments time consuming as the paperwork was unfamiliar and records of epilepsy, eye and dental reviews and immunisations were incomplete. Now she conducts many Health Assessments in minutes (MBS item 703). She feels that the annual Health Assessments push her to check issues beyond the acute presentation. Once you get to know the patients, you re more likely to recognise a change in behaviour and investigate the cause. The Disability Support Worker completes the first section of the CHAP, and she reviews the history and completes the examination; You don t always get exactly the examination you want she says with a smile. You just have to be patient. An effective partnership between GP and Disability Support Workers can streamline and optimise the benefit of the Health Assessments. The GP noted that there are many disability support staff involved in supporting a person with an intellectual disability and it is therefore very important to document the Action Plan. see the person when they are well and develop a plan to keep them well. In General Practice F the GP addresses health promotion and preventive issues in the annual Health Assessment. He likes to see the person when they are well and develop a plan to keep them well. Annual Health Assessments usually take him more than 60 minutes (MBS item 707). The Disability Support Worker fills out the CHAP and the GP reviews the history, performs an examination and uses the template in Medical Director software, Health Check intel disability, to document the annual health review. The GP appreciates the CHAP being based on research and prompting him to check health issues seen more commonly in people with an intellectual disability. Use the template in Medical Director software to document the annual health review At the end of the appointment he uses Medical Director Software to print an Action Plan and medication sheets (the printed version is easier for staff to read than handwritten forms!). Support Workers make follow up appointments to check on the progress for each separate issue that arises out of the annual health review. Give a copy of the Action Plan to the resident and support workers because good communication between support staff is essential to ensure recommendations are carried out when multiple staff are involved General Practice G is a rural practice providing care to six residents with a disability in a group home. Each year the clinic sends a reminder to residents when their annual review is due.

7 At a recent review, the GP identified high cholesterol and borderline glucose intolerance. The resident was referred to a Dietitian. Support Workers and the dietitian have assisted the resident to develop and follow a meal plan and to increase physical activity. The GP reviews the resident every three months to measure changes in weight, cholesterol and glucose levels. Before and after photographs of the resident helped her recognise the progress she has made and motivate her to continue with her program. The GP has identified many cases of Vitamin D deficiency and ensures bone density tests are completed when necessary. She uses the annual health assessment to review residents medications. In one case, an overweight 26 year old woman had been on Olanzapine for seven years despite no psychotic illness having been recorded. The GP slowly reduced and finally ceased the medication over a number of months. The patient is now happier more energetic, and has returned to a normal weight. The GP says good communication and documentation between Disability Support Workers and health professionals is essential to ensure recommendations are carried out when multiple staff are involved. She uses the template in Medical Director ( Health Check intel disability ) to guide her through the Health Assessment process and to print out the Action Plan. A copy of the Action Plan is provided to the resident and Support Workers. The CHAP reminds me to think about dental, hearing and vision issues In General Practice H the GP reports that the CHAP ensures health assessments are comprehensive, and reminds her to think about dental, hearing, vision and other issues. She has also found the information provided about specific syndromes helpful in caring for her patients. She uses the recall systems in Medical Director software to ensure immunisations, thyroid function tests and breast screening are up to date. Pap smears are tricky for women with an intellectual disability who may have an unknown sexual history but she relies on her clinical judgement and works the issues through with the Disability Support Workers and family when appropriate. Another patient with Cerebral Palsy has clear indications and consent, but physically doing the Pap test was difficult. The situation has greatly improved since the practice acquired a height adjustable bed. The GP provides this advice to her colleagues in relation to Health Assessments: Ask the Disability Support Workers to collect the history, including searching archived notes and talking to the person s family, to ensure information provided in the first section of the CHAP is as comprehensive as possible. Support Workers and family members can provide valuable information about a change in behaviour that may indicate physical or mental health issues. Ask staff to the CHAP to the clinic ahead of time and book long appointment (30-60 minutes according to need). It takes time especially if the patient has communication and/or mobility issues. Ask the practice nurse to review the first section and complete as much of the second section of CHAP as possible. Support workers are very helpful in assisting the GP to communicate with the person. Don t try and do anything else but the Health Assessment in that appointment. Ask the patient to return for other issues. Print off information and Action Plans so staff know what to do. They are the ones who will be implementing Action Plan items such as increasing physical activity and good nutrition programs and ensuring the person is supported to attend appointments and reviews.