Health Assessments for People with an Intellectual Disability making them work and making a difference 2011

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Background In May 2010 the previous MBS items 718 and 719 for a comprehensive health assessment for a person with an intellectual disability were replaced with four new time-based items • Item 701 Brief health assessment of less

than 30 minutes duration. New fee $56 • Item 703 Standard health assessment

lasting more than 30 minutes but less than 45 minutes. New fee $130.10 • Item 705 Long health assessment lasting

more than 45 minutes but less than 60 minutes. New fee $179.45 • Item 707 Prolonged health assessment

lasting more than 60 minutes. New fee $253.60

In December 2007 the Comprehensive Health Assessment Program (CHAP) was introduced to 550 group homes for people with an intellectual disability in Victoria across the state. CHAP is a tool designed to prompt a comprehensive health assessment for adults with intellectual disabilities. This may assist doctors make better diagnoses, provide appropriate treatment and ultimately ensure an overall better health status. General Practices are very busy and the annual health review for a person with an intellectual disability can be time consuming. The following eight case studies are based on interviews with General Practitioners (GPs) and Practice Nurses (PNs) who have successfully implemented these MBS items in their practice.

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’Practice nurses can assist with annual health reviews for people with an intellectual disability‘… A A is a Practice Nurse in a busy rural health service. GPs in the practice identify patients with an intellectual disability on the GP software system. A organises appointments for the annual health reviews and encourages Disability Support Staff who will be attending with the client to contact the Practice Nurse or Practice Manager at the GP clinic beforehand to ensure annual health reviews progress smoothly. A completes the documentation for the annual health review on the computer, the GP reviews it during the consultation and a copy is provided to the patient. Health issues that are identified by the annual health review process are dealt with in more detail in follow up appointments and Team Care Arrangements are organised for patients as needed. This has allowed some patients to access allied health professionals with some of the cost covered by Medicare payments.

Practice Nurses are well connected through the Divisions of General Practice to local service providers such as council services, allied health and women’s health services. A described the important role of the support workers who assist him to communicate with the patient, provide information about the person’s health and day to day life. A noted how important it is to document the outcomes of the appointments because of the multiple people involved — the patient, Support Worker, family, GP, Practice Nurse and referral agencies. A aims to make sure that women with an intellectual disability are offered the same screening for breast and cervical cancer as other women and that their need for contraception is assessed. A organises for automatic annual reminders to be sent to people with an intellectual disability.

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‘The annual health reviews get easier as you get to know the patients and do subsequent reviews’… Dr B Dr B is GP to thirty people with an intellectual disability living in six group homes. His role includes completing annual health reviews, updating medication charts and following up on health issues. Dr B finds the annual health reviews are clinically important to do. He has picked up issues such as congenital cataracts in a person with Down syndrome, many cases of Vitamin D deficiency and many cases of reduced hearing due to excessive amounts of ear wax. Dr B finds it very important to check bone density through ultrasound in this group of patients. In one house he noticed a common finding in the annual health reviews. All the residents had gained a considerable amount of weight in one year so he organised for a referral to a Dietitian. The staff were quite resistant to this idea but he was firm about it. At a recent annual health review he was able to reduce the doses of several medications for a patient which greatly reduced the side effects they were experiencing. Dr B now uses the Comprehensive Health Assessment Program (CHAP) rather than the Medicare proforma because CHAP is more thorough. Dr B’s advice to GPs is ‘don’t get despondent about doing the annual health reviews. They get easier as you get to know the patients and as you do subsequent reviews. CHAP guides you to do an annual health review – just follow the prompts. Annual health reviews are worth doing — you pick up quite a few issues that need addressing’.

Dr B finds that the first time he completes an annual health review for a new patient, it can take a long time — well over an hour. The time based Medicare items 705 and 707 allow for these longer appointments. It gets easier in the following years as the records are up to date. It is very important that the GP and Disability Support Staff work together as a team to assist the person to have an effective annual health review. Dr B’s advice to Disability Support Workers (DSW) is to complete the first section of CHAP to the best of your ability. This involves finding archived records and searching for information rather than just ticking ‘don’t know’ in section one. It is important to do this to keep track of the person’s medical history and make sure that previous diagnoses are not lost. He asks the staff to organise the blood tests in advance so he can review them at the time of the annual health review. The Disability Support Staff assist the person with urine tests. The staff prepare the person for the annual health review while Dr B reviews the paperwork. The staff take notes as the annual health review is completed so they know what further tests and referrals are required. Dr B updates his records following the annual health review. He makes sure he records what actions are needed as a result of the annual health review. He follows up to make sure the actions are implemented and records the outcomes. This makes the subsequent annual health review much easier. Good record keeping is important for this group of patients. The Practice Nurse organises Team Care Arrangements for patients as required.

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‘Annual health reviews are important for people with an intellectual disability at supported residential services’… Dr C Dr C is the GP to about twenty people with an intellectual disability and other complex psychiatric and mental health issues. To refresh his skills in this area, he attended a masterclass organised by General Practice Victoria where Dr Jane Tracy from the Centre for Developmental Disability Health Victoria (1) spoke about annual health reviews for people with an intellectual disability.

It took him just over an hour so he claimed the MBS item 707. An optometrist and an audiologist screen the residents once a year but the records are not well kept in the service so his paperwork is vital to retaining the medical history of this group of people. He refers women with intellectual disability for breast screens and pap tests to a female GP nearby if they prefer a female GP for these procedures.

He plans to conduct one annual health review each fortnight as well as following up on acute issues. He followed the guide in the Medicare Benefits Schedule (MBS) which described all the issues a GP should look for during an annual health review of a person with an intellectual disability.

Dr C feels that it is important to do the annual health reviews because the other doctors are locums so they don’t know the patients in the same way as he does.

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‘People who have moderate to severe intellectual disability have several disadvantages over others in relation to health care‘… Dr D Dr D completes about 100 annual health reviews for people with an intellectual disability each year using the Comprehensive Health Assessment Program (CHAP). His Practice Nurse provides immunisation sessions on-site for seasonal influenza and other adult vaccinations. He conducts the annual health reviews over two sessions and claims MBS item 707 for a prolonged session. The Disability Support Worker completes the first section of CHAP in conjunction with the person with an intellectual disability and brings the completed CHAP to the appointment with Dr D. Dr D finds the Support Worker’s documented observations, such as if the person’s behaviour has changed, are absolutely critical to knowing whether there is anything wrong with that person. Dr D then conducts the history and examination including reviewing the first section of CHAP and completing the second section of CHAP. Dr D uses the paper version of CHAP but uses Medical Director software to update medications and vaccinations. Dr D then organises relevant pathology and referrals. Dr D refers to experienced audiologists and ophthalmologists for vision and hearing testing. He refers women to Breast Screen Victoria because of their good reputation of working with women with a disability. Women with an intellectual disability are less likely to have children which may increase the risk of breast cancer.

At the second session Dr D reviews the results of pathology and referrals and together with the Disability Support Worker and the person with a disability works out an action plan which the disability support staff implements. The action plans must be documented because the turnover of staff means that the action plan can be forgotten. Dr D has seen the benefits of annual health reviews. He has picked up many cases of low Vitamin D levels, a case of haemochromatosis, breast cancer, undetected hypertension and many cases of inactivity and obesity. His advice to colleagues who have not conducted an annual health assessment is: ‘People who have moderate to severe intellectual disability have several disadvantages over others in relation to health care. • They may be unable to describe how

they feel, and often unable to recognise that what they feel is abnormal • Staff may change frequently so there is a

lack of intimate knowledge of their normal behaviour including such 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 we could add to the list. It is extremely satisfying to look after their health and develop a relationship with them as they seem to put even more trust in us than others. ENJOY’

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‘The annual health review pushes GPs to check beyond the acute presentation’… Dr E Dr E has been completing annual health reviews for people with an intellectual disability using the Comprehensive Health Assessment Program (CHAP) for three years. At first she found the annual health reviews time consuming due to the unfamiliar paperwork and because epilepsy, eye and dental reviews and immunisations weren’t up to date. Once Dr E had completed a few annual health reviews they became easier to do. She noted that ‘The more annual assessments you do the more organised you get’. Dr E feels that ‘the annual health review pushes GPs to check issues beyond the acute presentation’. Dr E conducts the annual health reviews in just over 30 minutes and claims MBS item 703 for a standard health assessment. The Disability Support Worker completes the first section of CHAP in conjunction with the person with an intellectual disability and brings the completed CHAP to the appointment. Dr E finds it valuable when the disability support staff complete the history part of CHAP as it frees her up to complete the examination and review the history. Dr E uses the paper version of CHAP and also uses Medical Director software to update her records.

Dr E noted that there are many disability support staff involved in supporting a person with an intellectual disability. This is why it is important to document the action plan. Dr E notes that she works in partnership with the disability staff and that they are getting really good at completing the annual health reviews together. Dr E has trained the staff to ask for all the blood tests to be done before the annual health review occurs. This enables Dr E to make decisions at the time of the annual health review and often saves a second visit. Dr E notes that all GPs are time poor, so she focuses on being efficient and organised. Dr E noted the importance of the patient doctor relationship over time. ‘Once you get used to seeing the clients and you know what they’re like normally, you’re more likely to recognise a change in behaviour and investigate the cause’. Dr E has seen the benefits of annual health reviews in terms of up to date immunisations and regular reviews for health issues. Her advice to colleagues who have not conducted an annual health assessment is: ‘You’ve got to be very patient. You don’t always get the examination you want.’

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‘Use the template in Medical Director software called ‘Health Check — intel disability’ to document the annual health review’… Dr F Dr F uses the annual health review for people with an intellectual disability to tackle health promotion and preventive issues. He likes ‘to see the person when they are well and develop a plan to keep them well’. Dr F usually needs more than sixty minutes to complete the annual health review and claims for MBS item 707 ($253.60) which is a prolonged health assessment item. At the end of the appointment he uses Medical Director Software to print an action plan. His patients make individual follow up appointments to check on the progress for each separate issue that arises out of the annual health review.

In Dr F’s experience of annual health reviews for people with an intellectual disability, the Disability Support Worker completes the first section of the Comprehensive Health Assessment Program (CHAP). This assists him in history taking. Dr F prefers to use the template in Medical Director software called ‘Health Check – intel disability’ to document the annual health review rather than using the paper based CHAP. Dr F finds the CHAP form fairly self explanatory and likes the fact that it is based on good research. It prompts him to check important issues for people with an intellectual disability. He also uses the medical director software to print updated medication sheets for the patient which staff find easier to read than hand written forms.

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‘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‘… Dr G Dr G is a rural GP who provides medical care to six residents with a disability in a group home. Each year the clinic sends a reminder to residents when their annual health review is due. At a recent annual health review, Dr G identified a new resident as being overweight with high cholesterol and borderline glucose intolerance. The resident was referred to a Dietitian and prescribed medication to lower her cholesterol levels. Dr G admires the work of Disability Support Staff when assisting the resident to follow her meal plan and to increase physical activity. Dr G has reviewed the resident every three months to measure the positive improvements in weight, cholesterol and glucose levels. Before and after photographs of the resident with Disability Support Workers showed staff had lost weight as well. Dr G has identified many cases of Vitamin D deficiency through annual health reviews and ensures bone density tests are completed when necessary. Dr G uses the annual health assessment to review residents’ medications. In one case, Dr G was concerned about a 26

year old woman who had been prescribed Olanzapine for seven years. A referral to a psychiatrist confirmed Dr G’s assessment that she did not have psychosis and the Olanzapine was stopped. The resident is much improved and happier as she is not experiencing side effects and has returned to her normal weight. Dr G finds that Disability Support Workers are very good at making appointments, being punctual, following up doctor’s recommendations and working in partnership with her. Good communication between support staff is essential to ensure recommendations are carried out when multiple staff are involved. Dr G uses the template for annual health reviews in Medical Director called ‘Health Check – intel disability’ to guide her through the annual health review process and to print out the action plan. A copy of the action plan is provided to the resident and support workers. It takes Dr G about 90 minutes to complete an annual health review and she claims MBS item 707 ($253.60) for a prolonged health assessment.

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‘I’ve previously completed annual health reviews for people with an intellectual disability but they were not as comprehensive as the ones undertaken using the Comprehensive Health Assessment Program (CHAP)‘… Dr H Dr H has previously completed annual health reviews for people with an intellectual disability but they were not as comprehensive as the ones undertaken using the Comprehensive Health Assessment Program (CHAP). Initially she found it overwhelming using CHAP but she soon realised that it was a very useful checklist because it is easy to miss areas such as dental health, hearing and vision. Dr H is used to focussing on acute presenting issues but she feels it is important to make time for an overall physical check up also. CHAP includes information about specific syndromes which has helped her to provide better care for her patients. She uses the recall systems in medical director software to keep immunisations, thyroid function tests and breast screening prompts up to date. Pap smears are tricky for women with an intellectual disability who may have an unknown sexual history. The consent issues are challenging and she relies on her clinical judgement. Another patient with Cerebral Palsy provides consent to have a pap smear but it is physically very difficult. Dr H has been using CHAP for a few years now and her advice to other GPs is: • Ask the support workers to search their

archived notes and talk to the person’s family to complete the first section of CHAP as fully as possible. Email CHAP to the clinic ahead of time. Ask the practice nurse to review the first section and complete as much of the second section of CHAP as possible.

• Ask the support worker to book a 30

minute appointment. You can’t rush the annual health review. It takes time especially if the patient has mobility issues. • The support workers are really useful

in helping the GP to communicate with the person, to assist with physical support and provide observations of behavioural change. They are also vital for implementing action plans such as regular physical activity and good nutrition programs for the people they support and ensuring the person is supported to attend referral appointments. • CHAP doesn’t integrate well with medical

software so use the template in Medical director in combination with the CHAP tool. • Don’t try and do anything else but the

annual health review in that appointment. If someone needs their ears syringed please book another appointment. • It gets easier and quicker with every year

as you gather the medical history and get to know the patient. Print off progress notes and action plans for staff so they know what to do.

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Resources The Centre for Developmental Disability Health Victoria http://www.cddh.monash.org/

A Guide to Better Primary Health Care for People with Intellectual Disabilities

MBS information: Health Assessments for People with an Intellectual Disability http://www9.health. gov.au/mbs/fullDisplay. cfm?type=note&qt=NoteID&q=A30

www.cddh.monash.org/better-primaryhealth-care-guide.html

GP Management Plan and Team Care Arrangements

Accessing Mental Health Services for People with Intellectual Disabilities

www.medicareaustralia.gov.au/ provider/business/education/files/2249quick-reference-guide-for-generalpractitioners.pdf

www.cddh.monash.org/assets/ documents/cddhv-health-services.pdf

Pap Tests: The Plain Facts www.cddh.monash.org/productsresources.html#pap

Comprehensive Health Assessment Program (CHAP) http://www2.som.uq.edu.au/som/ Research/ResearchCentres/qcidd/ Documents/CHAP%202010%20 brochure.pdf

Health Care Guidelines for Adults with Developmental Disabilities www.iassid.org/pdf/ healthguidelines-2002.pdf

Published by the Victorian Government Department of Human Services, Melbourne, Australia, October 2011 © Copyright State of Victoria 2011