Discharge Planning for People

with Disability Discharge Planning Conference: July

24 and 25 2014

Sandra Capito

Disability Nurse Consultant

Outline

Understanding disability services and how they work

Population health statistics for people with disability

Incidence of readmission and client outcomes-case studies

Specialist discharge planning for a person with a disability – where we

struggle and best practice

Communication is the key

Resources

What is a disability?

WHO-Disability is a complex, dynamic, multidimensional and contested

definition

“May be viewed as a medical or social model in which people are

viewed as disabled by society, not their bodies.” (WHO 2011)

Disability is an umbrella term for impairments, activity limitations and

participation restrictions that negatively impact on the way a person

interacts with their environment

May be congenital or acquired

Client Cohort

Ventilator support – VRSS Austin Hospital

Live independently in units supported by staff as required

Cognitive, physical, autism spectrum

Across age groups – 18 months up to aged

Medical conditions associated with aging- earlier onset in people

with some disabilities

Multiple and complex disabilities and health support needs

Staff Cohort

Disability support staff have a range of experience and skills.

Certificate III or IV in Disability is the most common, but a very

large percentage are learning as they go.

There is no qualification in the AQF that trains in the management

of health in the disability sector; this cohort have no pharmacology

education

The scope of practice for disability support workers varies from

state to state

What can disability

support workers do?

When appropriately trained, disability support workers can perform

the following procedures:

• Enemas and suppositories

• Tube feeding

• Catheter care

• Administer medication via set dose injector pen such as Epipen

• Nebulisers and vaporisers

• Blood glucose testing

• Shallow Suctioning

• Administer medication

• Oxygen administration

Tasks disability support

workers can’t do

Disability support workers cannot perform the following under any

circumstances:

• Administer medication by intramuscular or

intravenous injection.

• Insert or remove PEG tubes or catheters.

• Monitor or manage intravenous lines and

attachments.

• Managing sliding scale diabetes.

Yooralla Health Support Team Only disability service in the state with nurses working in health

management and staff training capacity

Health assessments; identification of support needs and planning-

transition and change of health

Develop health support plans

Clinical support during acute health events-hospital transitions, palliative

care

Train staff to provide health support-sit outside AQF

Impact on health management and support policy and

practice within the organisation

Disability health

Compared with people without a disability aged 15-64, those with

severe or profound disability were:

• More likely to have check ups with the GP: 81% verses

54%

• 2.5 times more likely to do so every 6 months

• 10 times more likely to do so once a month

Disability Health

Learning Disabilities Observatory – Hospital Admissions That

Should Not Happen.

Failure of primary health care

More common is people with disability of all ages – in the general

population more common in the elderly

Commonest cause of admission is epilepsy and convulsions,

constipation, diabetes, influenza/pneumonia

There admissions are long than for the general population

Healthcare for all Sir Jonathan Michael’s UK inquiry into access to healthcare for

people with learning disabilities.

Summary of findings:

• Insufficient effort to make reasonable adjustment to support equity of service

• Health service staff have limited knowledge about learning disability; not familiar with sources of assistance they may use

• Poor partnership between service providers; this is particularly problematic when a person cannot communicate their care needs themselves, or their support requires complex planning

Healthcare for all

Reasons identified for the inequity;

• People with disability are not visible within health

systems – data to identify needs is not available

• Lack of awareness of the health needs of people

with disability in primary health care

• Discrimination is not monitored in health care

services

• Poor undergraduate training

Identified reasons for

health gaps

Diagnostic overshadowing – a diagnosis of LD/ID as the accepted

cause for an unrelated illness/symptoms

People with learning disabilities, who challenge services – longer

appointments, hoists, communication aids

Capacity and consent

Not meeting carer needs – planning transitions of care

Case Study

June-Dec 2011 – Seen by medical staff 24 times – GP and A&E

presentations. Admitted 16 times; repeated story of increased debility

and ill health, behaviours indicating pain. Increasingly withdrawn –

would lie curled up on her bed

Dec 2011 discharged following an admission for chest infection but was

unable to ambulate around the service or transfer – Returned to A&E

Markers for CA

Palliative care was initiated

Died three months later

Specialised Discharge

Planning

It’s planning for discharge very early in the story

Start at pre-admission for planned hospitalisation

On admission for unplanned hospitalisation

Central hospital discharge liaison point/contact

Sometimes the right decision is to prolong hospital stay to ensure

that all planning is complete prior to discharge

Specialised Discharge

Planning

Discharge:

Improving communication tools to remove ambiguity

Summaries including communicating with key disability support

staff

Gain/release form addresses privacy issues and release of

information

Clear plan of action re: upcoming outpatient activity etc.

Specialised Discharge

Planning

• New medications

• Chemical restraints

• Pain management

• Post-op care

• Changes in feeding/ADLs

• Follow up appointments/recognising special needs at

discharge

Specialised Discharge

Planning

Avoiding hospital admissions -

Preventive practice

• Robust engagement with Primary Care – GP Annual Health

checks

• GPMP/TCA

• Screening – Breast screen, Pap Tests, bowel screening etc.

Communication as the key What Yooralla can do…

HST becoming a liaison point

Provide succinct and concise information about the client

• How s/he moves

• How s/he is fed

• How s/he communicates

• How pain is expressed – changes in behaviour

• Health support documentation including current

medications etc.

Communication as the key

Introduction to the eHealth record

Adequate information from GP

Importance of hospital staff to read the supplied information

Reasonable adjustment prior to admission

Communication as the key

Disability to be flagged on hospital database

Post-discharge follow up

Resources

Office of Public Advocate

http://www.publicadvocate.vic.gov.au/about-us

Department of Human Services

Hospitalisation of people living with disability supported

accommodation services

http://www.dhs.vic.gov.au/_data/assets/pdf_file/0009/747711/1_ho

spitalisation-of-people-living-in-disability-support-accommodation-

summary-1112.pdf

In 2007 MENCAP, a British disability advocacy group published a paper that

described the death of six people with a disability.

Death by Indifference.

The paper was followed by multiple Ombudsman, Parliamentary, NHS

Department of Health investigation and reports that identified the many and

manifest ways the health services failed to identify and meet the needs of this

client cohort.

These reports were followed by Jonathan Michaels report Healthcare for All

that identified recommendations for how health services could meet their

legislative and moral responsibilities for the care of this group

of patients

2012 MEDCAP Death by Indifference: 74 and counting

Death by Indifference:

The MENCAP Paper that started it all