Hunter Medicare Local

Health Coordination for people with Disabilities in the General Practice Setting

A guide for Group Home and General Practice staff

This seminar arose from a shared idea that there has to be a simple yet concise approach to Health Care for People with disabilities from a Home/Care

and General Practice perspective.

This shared idea comes from combined experience in both sectors, formerly as a Disabilities Nurse and

most recently as a General Practice Nurse undertaking Disabilities Outreach Services in

Inner West Sydney

To provide you with a process that will improve the health

outcomes for the people for whom you care

Our aim:

• Annual Comprehensive Health Assessment –

CHAP – Covered under MBS Items 703,705,707.

Specific to ID only-can be done annually.

• Development of a Health Care Plan

• Annual Dental Review

• Mental Health Review (if applicable)

• Healthy Lifestyle Plan in relation to diet, sun protection,

health promotion and disease prevention.

• Client Risk Profile and Intervention Plans

• Nutrition and Swallowing Checklist and Risk Plans as above

Early Identification of Health Risks

Accessing Appropriate and Responsive Practitioners• Identify and develop a relationship with ONE general practitioner and see

that GP at each visit if possible (may not be possible in “on the day” appts)• Large medical centres that only see pts “on the day” or charge to see

individual GPs should be avoided if possible-poor continuity• “shop around” – if your client/service is not happy-more difficult in

regional/rural/remote areas• Book client appointments well in advance –this is appropriate and

encouraged at most practices• People on multiple medications (>3 or 4) or on

some psychoactive medication should be reviewed at least 6 monthly – better 3 monthly.

• Identify practices that have a Practice Nurse – easier access - great client /carer education

Continual Review and Vigilance in Health Care to Improve its Quality• Health is not an annual event – monitor daily- observation & documentation

when changes occur• Regular planned review with GP and other associated health professionals-

not only when problems occur.• Up to date immunisation-clients AND staff• Review the Health Care Plan at least 3 monthly• Regular physical checks (non –invasive & with consent) – check behind ears,

between toes, groin, breast, under abdominal “flap” in obese clients etc.

Responsive communication between client, staff practitioners and families• Keep accurate, relevant and timely records

including communication books etc

Good and responsive communicationbetween client, staff practitioners and families• Keep accurate, relevant and timely records

including communication books etc• Identify a Key Worker who knows the client well

this person should facilitate and attend allhealth appointments.

• Most Health Professionals are not psychic! Always send comprehensive information/observations re behaviour to Drs appointments

• If you are unsure or unclear about what the health professional is saying/prescribing etc – SPEAK UP –ask them to write it down or write yourself and get their OK.

• Do not send new or unfamiliar staff to appointments with clients-particularly those who cannot communicate well –poor outcomes for client and service

• Keep in contact and update families regularly where appropriate- build and manage relationships!

For everyone, the Health Process can involve:

• Annual Health Assessments

• General Practice Management plans

• General Practice Management plan reviews

• Enhanced Primary Care Services

• Home Medication Reviews

• Chronic Disease Management

• Case Conferences

Annual Health Assessment

• Is a Comprehensive Annual Health Review

• Currently services use the CHAP or a variant

• Is completed annually by a GP

• The GP may be assisted by a Practice Nurse

• Can be undertaken in the surgery or at home• The GP/Nurse should be assisted by the

person being reviewed and, if required, the Key Worker for that person

General Practice Management Plans/ Care Plans• Document the person’s Health Issues• Detail prevention strategies• Detail intervention strategies• Detail any Allied Health/Specialist services• Detail the last review date, both GP and others • Detail next review date, both GP and others• Inform the Allied Health/Specialist services and obtain

their consent for participation in the Plan • Are reviewed on a 3 monthly basis with the GP• Involve the person and, if required , their Key Worker• Should be used to establish the “Facility based” Health

Care Plan for the person

• Occur 3 monthly

• Is to review ongoing health management

• Enables new health issues to be addressed

• Enables treated health issues to be placed in

past history for future reference if required

• Can parallel the 3 monthly Health Reviews

required by Service Providers

General Practice Management Plan/Care Plan review

Enhanced Primary Care/EPC services

These services may be provided by:• Podiatrists• Dietitians• Speech Therapists• Speech Pathologists• Physiotherapists• Occupational Therapists

Referrals are Annual for 5 visits in total per Calendar year

Home Medication Review

• Can be done annually• Is undertaken by qualified pharmacists• Is undertaken in the person’s home• Has a pre-determined set of criteria• Improves therapeutic use of medication• Lists medication interactions• Lists side effects of current medications• Provides opinions on future medication options

for improved outcomes• Provides alerts to GP’s and Care staff for

future monitoring

The Home Medicines Review (HMR) is vitally important as it ensures that the medication in the person’s GP medication list, matches the Webster (prepacked) medication that is in the home, and that both these records match what the pharmacist has in their dispensing records.

And further, at each GP visit, it is good practice to check the medication chart/Webster pack and the list of medications in the GP notes for that person.

Chronic Disease Management

Involves the monitoring and ongoing assessment of any Chronic Disease including:

• Diabetes

• COPD/Emphysema

• Asthma

• Alcohol abuse

• Obesity

• Chronic pain

Case Conferences

Can be held when required but must involve:

• the person

• the GP

• a carer/key worker if required

• Specialist /Allied Health staff providing services

An Outline of the Health Assessment process

•The Key Worker completes Part 1 of the Annual Health Assessment

•This should include an update of all appointmentsattended in the last 12 months, particularly: Dental, Audiology, Optometry, Podiatry

•The GP should have received reports fromother Specialists for consultations that have occurred throughout the year, however,

•A list of Specialist appointments attended by the person being assessed may be helpful in determining if all reports have been received by the GP

It is vital that, if required, the person who helps complete Part 1 of the Health Assessment is the person with the most knowledge of the person being assessed, and again, if required, also attends the GP appointment.

This enables the GP to receive as accurate a clinical picture as is possible, ensures the

accuracy of theHealth Assessment and most importantly,

gives the best health outcome for the person being assessed

The GP then completes the medical examination and Report

This report should include:•A summary of Existing Problems•Opprtunities for Prevention•Opportunities to improve Medical Management•Opportunities to improve Quality of Life

The conclusions made in the Annual Health Assessment now drive the Care Planning Process

Care Plans generally give:

•An Active Medical History•A Past Medical History – if warranted•A List of Current Medications•Details of Allergies•A List of Health Problems and/or Needs•Health Goals•Treatments and Services required•Arrangements and Contact Details for the providers of the Treatments and Services

The Care Plan has two Review processes.

•The first is a review at 3, 6 and 9 months after initial completion. These reviews briefly detail progress towards the Health Goals, giving recent and future appointment dates with allied health providers and/or specialists

•The second 12 months after initial completion is the:

Annual Care Plan Review,again coinciding with the

Annual Health Assessment