A Guide to Better Primary Health Care of Patients with an Intellectual Disability
Whilst most GPs will manage only a small number of patients with an intellectual disability (ID), patients with ID receive most of their primary health care through general practice. Communication difficulties and limited access to care can mean that the health needs of this group are often under-recognised. A systematic approach will assist us to better recognise and meet their needs. The RACGP website www.gplearning.com.au has 6 modules aimed at supporting GPs managing patients with intellectual disability. These include a category 1 active learning module "Comprehensive Care for People with Intellectual Disability" and category 2 learning activities.
This resource is aimed at supporting GPs in their vital role and highlights some of the challenges in this work as well as some initiatives aimed at assisting GPs.
For all patients with an intellectual disability, consider:
Has this patient had an Annual health assessment for a patient with an ID in the past 12 months?
All patients with an intellectual disability (ID) are eligible for an annual health assessment (one per patient in any 12 month period). This is an evidence based service funded by the Medicare Benefits Schedule (MBS), which recognises that the health needs of patients with an ID are often unrecognised.
The annual health assessment provides an opportunity for the GP to identify and manage any health problems as well as to undertake disease prevention.
Patients (or their carers) might request a health assessment or they may be identified by the practice when they present in relation to another matter or through practice audit.
Prior to attending for a health assessment, the patient’s carer will often provide the GP with a Comprehensive Health Assessment Program (CHAP). The CHAP is a health assessment tool which provides information about the patient’s past history and guides the GP through the health assessment by prompting the GP to be aware of commonly missed, difficult to manage or syndrome specific health conditions for patients with an intellectual disability. It is the GPs decision whether to use CHAP or not.
Completion of the annual health review usually includes review of medications, preventive health measures, detection of co-morbidity, identification of risk factors and management of active health needs. Findings may prompt further investigation or referral, or development of a GP Management Plan/Team Care Arrangements.
From 1 May 2010 the following item numbers can be used for an annual health assessment:
| Item 701 | Brief Health assessment of <30mins duration | $55.00 |
| Item 703 | Standard Health Assessment >30min and <45min | $127.80 |
| Item 705 | Long Health Assessment >45min and <60min | $176.30 |
| Item 707 | Prolonged Health Assessment >60min | $249.10 |
Details of the requirements of these items can be found at Medicare Benefits Schedule (MBS) Questions and Answers website.
Check the fee through the current Medicare Benefits Schedule at www.health.gov.au
The North East Valley Division of General Practice has Medical Director and Best Practice templates for health checks on their website developed in collaboration with the CDDHV at Clinical Software Template Downloads – Health Assesment website.
Is a Home Medicine Review (HMR) warranted?
HMR is valuable where there is polypharmacy, a complex medication regime, compliance concerns, drug interactions, swallowing difficulty, communication barriers, a requirement for drug level monitoring, etc. Many patients with an ID will be eligible for a HMR.
Item number 900 – $143.40
Check the fee through the current Medicare Benefits Schedule at www.health.gov.au
Would this patient benefit from other chronic disease management services?
Consider completion of a GP Management plan (GPMP) +/- Team Care arrangements (TCA) where the patient has a co-morbid chronic disease and complex care needs.
Item 721 GPMP – $133.65, Item 723 Team Care arrangements – $105.90
Check the fee through the current Medicare Benefits Schedule at www.health.gov.au
Does this patient exhibit any behaviours of concern?
It is not uncommon for a patient with an intellectual disability to present with concerning behaviours, usually described by their family or carers. These might include self-injurious behaviours, unexplained irritability or aggression, excessive or unusual vocalisations, etc., and may be a manifestation of an underlying medical condition or psychiatric disorder. Communication difficulties can make diagnosis difficult.
GPs should take a thorough history of the behaviour of concern (including triggers, exacerbating and relieving factors) as well as undertaking a detailed physical assessment of the patient.
Management should be based on the following considerations:
- Is there an underlying medical diagnosis?
Consider pain, constipation, Urinary Tract Infection, itch, Gastro-oesophageal Reflux
Disease(GORD), etc - Is there a psychiatric diagnosis?
Consider anxiety, depression, psychosis, etc - Have environmental or other triggers been identified and addressed?
- Does the behaviour constitute a serious risk to the client or to others?
- Is medication required?
The use of medications primarily to manage difficult behaviours should only occur after
the exclusion of underlying diagnoses and consideration of environmental and other triggers or in situations where the behaviour presents a significant danger to the person or others. - Have you reviewed all medications, including those currently used to manage behaviour?
- Are there other interventions that might be effective in place of medications?
- Would the client benefit from specialist review?
Note that Victorian Legislation defines chemical restraint as the use of a chemical substance to control or subdue a patient for the primary purpose of behavioural control. It does NOT include the use of a drug prescribed by a medical practitioner for the treatment of mental or physical illness.
The Management Guidelines: Developmental Disability provides GPs with further advice on the assessment and management of these behaviours.
What specialist support is there for GPs managing patients with an ID?
Listed below are some referral options GPs may employ to seek assistance/support in managing this client group.
Centre for Developmental Disability Health Victoria (CDDHV)
CDDHV supports GPs by providing telephone advice as well as accepting referrals for assessment and short term management.
Phone: +61 3 9902 4467
Fax: +61 3 8575 2270
Email: CDDH@med.monash.edu.au
CDDHV website
Psychiatric Services
For clinical concerns re mental health or to seek advice on the appropriate use of psychotropic drugs GPs may consider referral to private Psychiatry, Area Mental health services or a Primary Mental Health team (PMHT).
Local access and expertise in the field of disability will vary.
The RACGP provides a Directory of Private Psychiatrists that can be searched according to location and special interest in intellectual disability.
Victorian Dual Disability Service (VDDS) can provide GPs with phone advice regarding patients with the dual disabilities of developmental disability and mental ill health.
Phone advice is via +61 3 9288 2950; a response will be received within 24 hours. Direct GP referrals are not accepted.
For Children
Victorian Paediatric Rehabilitation Service at the Royal Childrens Hospital
Department of Developmental Medicine
