Purpose of Protocol
While many individuals with intellectual disabilities enjoy stable health and require only routine and episodic health care interventions, a small percentage of the population have complex health care issues or newly diagnosed conditions that require a more sophisticated clinical review and an in depth health care management plan.

This document sets forth a protocol for a clinical consultation for individuals with physical health care issues that by virtue of their complexity or need for management require a more in depth review than is typical of the standard ISP or other planning processes. Its primary purpose is to provide an opportunity for a clinician, in most cases an RN or NP, to offer valuable guidance to those supporting an individual regarding the specific issues a particular medical condition might present and the programs and supports that will assist the person to manage effectively.

To Whom Does this Apply?
All individuals eligible for our services may receive a clinical consultation, if deemed appropriate, regardless of whether they live in a Department-funded residential support, live independently with minimal assistance, or live with their families.

The clinical consultation will be provided either by the provider, if they have a nurse on staff, or by the area nurse if the provider does not have access to nursing support or the provider nurse would find a consultation by the area nurse helpful.

Health Status Indicators that Require Clinical Consultation
The following list represents several conditions or factors which should trigger the need for an in depth clinical consultation. The list is not meant to be all-inclusive. Providers and/or service coordinators may request a clinical consultation if in their professional judgment, there are issues which require further attention.

  1. Frequent Emergency Room visits or hospitalizations (This would apply to ER visits and hospitalizations that are not expected as a result of a particular chronic condition or as part of a protocol for management of a chronic condition. For example, visits and hospitalizations for pneumonia or sepsis would be included. Visits and hospitalizations to manage G/J tube placement or side effects from cancer treatment would not be included.)
  2. Newly diagnosed conditions including: (The conditions listed below typically require some major adjustment in the support structure for the individual especially around staff training, clinical support and appropriateness of current placement)
    1. Diabetes
    2. Cancer
    3. Dementia (including Alzheimer's Disease, organic brain syndrome)
    4. Cardiac or Pulmonary condition (For example, angina, congestive heart failure, emphysema, asthma, pulmonary edema, coronary artery disease)
    5. Autoimmune Condition (AIDS, HIV positive, Lupus)
    6. CVA (stroke)
    7. Dysphagia (swallowing difficulties that require specific intervention as ordered by the HCP or speech or occupational therapist)
  3. Major chronic condition with deteriorating outcome (Conditions that would be included here are those that, other than those listed above and below, create major lifestyle adjustments for individuals and their care providers and are likely to change the level of support an individual requires. Some examples are: Traumatic Brain Injury, Multiple Sclerosis, Parkinson's Disease, Huntington's Chorea, kidney disease requiring dialysis, Cirrhosis, amyotrophic lateral sclerosis)

    Recently placed G/J tube or other implantable device (This would include pacemakers, implantable seizure management devices, a trach cannula, devices for pain management)
  4. Large bone fracture or multiple fractures (The issue of safety needs changes as a result of aging or a disease process may need to be considered. Underlying cause of fractures will also need to be evaluated; for example, osteoporosis.)
  5. Lack of consensus re: diagnosis, treatment, treatment options or support needs (The Clinical Consultation may provide objective analysis of the situation that can help clarify and unify efforts in providing appropriate care for the individual involved.)
  6. Unexplained DNR (This would refer to DNRs that are put in place when there is no diagnosis or condition that would indicate a need for one.)
  7. Multiple pneumonias / Choking Episodes (The purpose of the Clinical Consultation in such a case would be to determine if due effort was being made to determine cause of recurring pneumonias as in chronic aspiration due to gastroesophageal reflux disease (GERD) or swallowing disorders or in management of early symptoms of respiratory infections.)
  8. Sudden, unexplained behavior change (Underlying medical conditions that are undiagnosed or not appropriately treated should be ruled out prior to exploring any type of behavioral intervention)
  9. Rapid decline in functional skills (Underlying medical conditions that are undiagnosed or untreated should be ruled out before other non-medical interventions are explored.)

When is Clinical Consultation is Initiated?
A clinical consultation should be requested whenever any of the following situations occur:

  1. Any of the abovementioned 10 factors occur
  2. The ISP team determines that the individual's health care status requires a more intensive clinical review than is possible by the team
  3. The completion of the provider generated "Health Status Review and Reporting Checklist" as part of the annual ISP process reveals health issues that the team feels is of concern.

Who Initiates a Request for Clinical Consultation?
A clinical consultation request may be initiated by any of the following:

  1. A supervisor, manager, health care coordinator, RN from the provider agency,
  2. Family member
  3. Any member of the ISP team
  4. Department nurse

Process/Flow for Clinical Consultation

  1. The individual's service coordinator or service coordinator supervisor should be contacted whenever any of the abovementioned indicators are present.
  2. If the provider has a nurse on staff who is assigned such duties, the provider will conduct the initial clinical review with consultation and support from the area nurse, if requested by the provider
  3. The service coordinator will forward a request for a clinical consultation to the area nurse, if the provider does not have an RN or NP assigned such duties
  4. The area nurse will respond to a request for a clinical consultation in a timely manner
  5. Findings and/or recommendations from the clinical consultation will be forwarded to the provider and service coordinator whose responsibility it will be to consider its inclusion in the individual's plan of care
  6. Each area office will maintain a record of individuals who have received physical health care clinical consultations.
  7. The area office nurse shall review and update each individual consultation at a minimum, in conjunction with the ISP process.

Elements of the Clinical Consultation
The clinical consultation is comprised of the following elements:

  1. A review of specific conditions identified
  2. A general assessment of the supports needed to effectively assist the individual and/or provider to stabilize and support the individual
  3. An assessment of the supports in place to meet the individual's needs
  4. A determination of how often the support plan should be reviewed to determine its efficacy in meeting the individual's health care needs.
  5. A recommendation regarding staff training needed to support person

* Please be aware that an Area or Regional nurse is available to you or your staff regarding any urgent issues or cases for which you feel their services could play a supportive, informative or intermediary role.

This information is provided by the Department of Developmental Services.