Transcript presentation

Learning Primary Health Care
to Serve Adults with
Developmental Disabilities
CPHA 2008 Annual Conference
Halifax, N.S.
Brian Hennen, MD MA CCFP FCFP FRCGP
Professor of Family Medicine, Dalhousie University
Background
• Ontario committed to closing last three large
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remaining institutions serving as residences for
persons with Developmental Disabilities
Significant advocate support but also pushback
from many present residents & their families as
well as staff
Ministries of Community and Social Services and
Health and Long Term Planning wish to ensure
smooth deinstitutionalization process
Background (cont’d)
• Concerned practitioners, administrators
and academics aware of the need to
support primary care providers to whom
the residents will be transferred
• See opportunity to improve primary care
to all persons with Developmental
Disabilities
• See opportunity to strengthen health
professional education programs in
Developmental Disabilities
Steering Committee
William Sullivan (chair), Elspeth Bradley,
Tom Cheetham, Richard Denton, Greg
Gillis, Maria Gitta, John Heng, Brian
Hennen, Barry Isaacs, Jo-Anne JacksonThorne, Marika Korossy, Yona Lunsky,
Shirley McMillan, Leeping Tao.
Steps Forward
• Acquire financial support for program
• Plan Colloquium of Involved Disciplinary Experts
to Develop Clinical Practice Guidelines (CPG’s)
and Practice Tools (lit searches, position papers,
discussion, consensus)
• Consult Experts on Guideline Development
• Publish CPG’s in Peer-reviewed Journal
Steps Forward (cont’d)
• Develop Training Program Proposal
• CFPC (Mainpro-C), RCPSC study credits
• Fund and implement Training Program
• Evaluate Training Program
Goal & Objectives
• To teach primary health care providers the
Clinical Practice Guidelines:
– 1. promote facility in the use of the CPG’s
– 2. identify/address barriers to using them
– 3. foster inter-professional learning
Learning Objectives
(i) apply new learning in caring for Adults
with DD:
. general issues in primary care (1-7)
. physical health (8-17)
.behavioral/mental health (18-24)
.specific syndromes
.assess family/community resources
.institute comprehensive management
Learning Objectives
(ii) Enhance skills:
• Apply CPG’s and practice tools to individual
cases
• Communication & rapport
• Acquiring informed consent
• Assess/monitor challenging behaviours
• Screening
Learning Objectives
(iii) Assessing attitudes & ethical approach
- Self assessment
- Societal assessment
- Service Systems assessment
- Focus on gaps (resources, transitions, silos)
Learning Program & Methods
• Reading/discussing CPG’s in workshop in
inter-professional small groups (all)
• Case presentations (4) staged on website
• Regional group, web case discussion (chat
rooms) by individuals, home-based input
Learning Methods (cont’d)
• Regional teleconference, home-based,
facilitated discussion, ending in groupdeveloped management plan for each
case
• Final workshop (all) comparing/discussing
management plans and evaluating
program
Four Cases (modules)
• 55 yr f with severe DD, cerebral palsy, and no
genetic diagnosis
• 46 yr m with moderate DD and Down Syndrome
• 18 mo f suspected of DD, returns at 19 yrs with
mild DD, sleep disturbance & behaviour problem
• 18 yr f with mild DD, severe behaviour problems
and no genetic diagnosis
Module Participant
• “This videoconference is helping me bring
things together in my practice. It is
helping me to know where to focus my
attention. The tools presented have been
especially helpful. It has also been able to
give me information and knowledge that I
was not necessarily aware of.”
Program Evaluation
• Overall:
– 29 % above average
– 71% excellent
Relevance:
-- 33% above average
-- 67% very relevant
(1-5 rating scale)
Program Evaluation (cont’d)
1-5 rating scale (Disagree/Strongly Agree)
• Objectives clearly stated
4.35
• Adequate time/module
3.74
• Video/conf format enhanced learning 4.34
• Format was interactive
4.48
Program Evaluation (cont’d)
• Peer feedback helpful
• Cases useful in applying CPG’s
• Available resources useful
• More confident caring for patients
4.61
4.61
4.57
4.52
Program Evaluation (cont’d)
• Would like to have spent MORE time on:
– Each module (n=4)
– Consent issues (n=3)
– Crisis plans, discussion of tools, assessing autism,
cerebral palsy mobility, fetal alcohol, advanced
directives, medications, genetics, psychological
testing, oral care (feeding, swallowing), psychiatric
management, role of nursing specific syndrome
Program Evaluation (cont’d)
Remaining Problematic Issues:
Increasing knowledge, networking with other
disciplines, definition discrepancies,
access to services (Dual Diagnosis, Psychological
Assessment, Genetics), insufficient time and
material resources, support for caregivers in
crisis situations, legal issues of education/care
from adolescence to adulthood
Program Evaluation (cont’d)
• Recommendations for Improving Program:
– Allow more than 2 wks per module (7)
– Send all modules at beginning (2)
– Direct guidelines more to OHP’s
– Periodic updating of CPG’s
– More interactive (I order test & get results)
– Raise visibility of program
Program Evaluation (cont’d)
• What tools will be most helpful in practice?
Comprehensive Health Assessment Program (CHAP) (4)
Crisis plan (4)
Periodic Health Assessments (3)
Checklist for Autism in Toddlers (CHAT) (2)
Office Visit Background (2)
All (2)
Program Evaluation (cont’d)
• Suggested Future topics:
Genetic Testing (3)
Psychological testing (2)
The Aging DD population (2)
Program Evaluation (cont’d)
• Other Suggested Topics:
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advance directives/consent/SDM’s
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current cases/dual diagnosis/special diets
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multidisciplinary collaboration/pharmaRx
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health assessments/health promotion
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highly complex cases/crisis plans
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decline in cognitive function
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staff training/staff assignments
Program Evaluation (cont’d)
• What attracted your participation?
To improve my care to persons with DD (6)
To increase my knowledge about DD (6)
An interest and wish to be supportive (2)
Program Attraction (cont’d)
“It was pertinent to my job and brought together the
health care needs of people with DD without having to
do extensive research on my own”, …….“boss
encouraged me”,
an opportunity for well-researched clinical approaches and
to meet other professionals in the field,
increased deinstitutionalization, aging population,
Program Evaluation (cont’d)
• 96 % of 22 would be interested in similar
courses in the future
• 96% of 22 would be interested in
participating in a provincial network
Case Development
• Real cases, modified
• Purposefully selected cases:
– Wide range of topics
– Mixed age, sex, diagnosis
– Overall use of guidelines and tools
• Suitable for range of primary care
providers
A Case Module Consisted of:
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Case description (sequenced sections)
Information re: CPG’s & tools applied
Question sets (5) posted at decision points
Group discussion board (up to 15 pages)
2-weekly on-line grp discussion (1 hr)
Last group discussion mgt. plan
Final all groups mtg. share/discuss/evaluate mgt
plans & course
Module Evaluations (Example
Module for case 1)
• Content:
– Met stated objectives
– Relevant to my practice
– Tools were useful
4.33
4.42
4.50
– Overall
4.55
Module Evaluation (Example
Module for Case 1)
Process of Discussion
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Time adequate
Clear presentation, well–timed
Discussion Board Interactions helped
Moderator kept discussion moving and
timed questions well
– Participants shared in the discussion
3.82
3.64
4.27
– Overall Discussion rating
4.22
4.27
4.27
Module Evaluation (Example
module for case 1)
• Website and Videoconferencing:
– Easy to access website
4.08
– Tech instructions/supports helpful 4.36
– Able to access areas of website
4.25
– Able to post comments on website 4.17
– Video/conf mtg helped in mgt plan 4.45
– Overall web/videoconference rating 4.40
Module Evaluation (Example Using
module with case 1)
• Most important thing learned:
– Getting relationship with patient and caregiver
– CHAP, periodic health exam, preventive check list,
management plan
– GERD management
– Using the internet for a course
– Specific guidelines
– I’ll look more closely at the physical aspects
– Issues of consent
Module Evaluation (Example of
module for case 1)
One change in learning process to improve it for you:
-more info at beginning re: web medium
-more time for 1st case, getting used to web
-one question not clear
-more interaction on the discussion
-need to make the time (spent 20 mins/day)
-more on Dual Diagnosis
-loosen up timelines