Quality Is No Accident

Massachusetts DDS · Quality & Risk Management Brief · Apr 2012 Issue#5

Preventive Screenings
Promoting Health for All

Preventive health screenings are important for all people, but especially for people with Intellectual and Developmental Disabilities (I/DD). Adults with I/DD may have special screening needs due to different patterns of illness or complex interactions between different medical conditions. Commonly under-recognized health care problems in this population include gastrointestinal problems like GERD or constipation, vision concerns, aspiration, Urinary Tract Infections (UTI’s), chronic/recurrent infections like sinusitis, respiratory disease, musculoskeletal conditions like osteoporosis or degenerative joint disease, and neurological conditions.
Screening Recommendations
DDS developed guidelines to assure that people with ID receive the same consideration for preventive health care screenings as the general population. Too often, health care providers assume that a particular screening is not necessary or too difficult to perform, simply due to a person’s disability. Anxiety and fear or difficulties in physical access may also prevent people from getting needed tests. In some cases, people with ID are not able to describe signs and symptoms of illness. Regular screenings become even more important for these people as they may lead to early detection and improved treatment outcomes.
Strategies to facilitate preventive screening
Barriers to screening can often be overcome successfully through staff advocacy and planning. Support staff and nurses, in particular, have an important role to play in assisting people with I/DD to access appropriate facilities and advocate that individuals receive the proper screenings.  

DID YOU KNOW?

85% of adults in DDS-funded residential supports had an annual exam in either 2010 or 2011; 37% of adults living in their own home or with their family had one.

67% of adults in DDS-funded residential supports and 20% of adults living in their own home or with family received a flu shot in 2010 or 2011.

At least 30% of adults with I/DD have syndromes and unique health problems that require additional screenings.

83% of adults in DDS-funded residential supports received a dental exam in 2010 or 2011. DDS recommends a dental exam every 6 months.

Both men and women with I/DD tend to experience decreased bone density at younger ages than people without I/DD.

Quality Is No Accident was developed by the Center for Developmental Disabilities Evaluation and Research (CDDER) of the E.K. Shriver Center/University of Massachusetts Medical School in collaboration with the Massachusetts DDS

Recommendations customized to adults with ID from the Mass Health Quality Partnership. Please consult health care providers when determining whether a specific examination is needed. Please refer to DDS website (listed below) for complete guidelines.
Screening	Recommendation	
Physical Exam	 Annual visit with a health care provider to assess changes in health and to plan preventive screenings and immunizations.	
Immunizations	Annual flu vaccine.  Pneumonia vaccine once, and at least a booster at age 65. HPV vaccine (3 doses) for those aged 9-26.	
Cancer Screening	All: colorectal screening starting at age 50; total skin examination annually after age 40 regardless of skin color;
Women: annual mammogram ages 50-69; pap smears and pelvic exam every 2 years through age 29 and every 3 years at ages 30-65+, depending on risk factors; 
Men: discuss possible testicular & prostate screening ages 50-75.	
Osteoporosis	Bone density screening starting at age 19 when risk factors are present.  Annually age 50+.	
Infectious Diseases	Periodic testing for STIs, HIV, Hepatitis B and C if at risk due to sexual or drug behaviors, or if pregnant; TB skin test every 1-2 years if at risk .	
Vision & Hearing	Assess hearing annually and refer to audiologist as needed; All people, even those who are blind, should be under an active vision care plan from an eye specialist (optometrist or ophthalmologist).	
Dental	Exams every 6 months.	
Other Considerations	People with I/DD may be at greater risk for osteoporosis, swallowing disorders (dysphagia), aspiration, cardiovascular disease, and diabetes. Screen as appropriate based on risk factors. Refer to screening guidelines for more information. 	
Complete preventive health recommendations can be found on the DDS website including a brochure and screening checklist
http://www.ma.gov/dds (Select “Health Promotion and Wellness Initiative”, then “Preventative Health Screening Recommendations”)

Preventive Health Screening Recommendations

      

DDS Health Promotion and Coordination Initiative
DDS is enhancing the quality of health care that individuals with I/DD receive by focusing on the important role that direct support professionals play in health care advocacy, including:

•	The preventive health screening recommendations listed above.
•	A health review checklist which is completed by direct support professionals and taken to every primary care appointment to aid in communication and follow up.
•	Required electronic health care records for all individuals receiving residential supports.
•	Easy to use informational sheets for observing and reporting signs and symptoms of illness.
•	Tools for health care coordination. 

All available here: http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/intellectual-disability-support/health-promotion/

Strategies to Ensure Access to Screenings

Advocate for Screenings
•	Staff or family members can be effective advocates for preventive screenings. 
o	Staff who accompany a person to the annual physical should be familiar with the person’s preferences for support, communication styles, and needed accommodations.
o	Advocates should be knowledgeable about which screenings would be appropriate to discuss with the physician or health care provider at the annual visit. The DDS Preventive Health Screening checklist can assist with this process. 
Reduce Fear and Confusion 
•	Many adults feel more comfortable at a medical visit if they feel adequately prepared for the event. Detail in advance about logistics of a test, what to expect and why it’s important.
•	Listen to the person’s concerns and address them.
•	Prepare for exam procedures by tailoring information to the person’s level of understanding; show, don’t tell.  For example, show what may happen during a screening on a staff person or doll, or introduce unfamiliar items such as a stethoscope or a blood pressure cuff at home to allow the instrument to become more familiar.
•	If the person is particularly anxious, talk with the health care provider about the possibility of booking multiple appointments to allow time for the person to become comfortable.
•	Be clear about why consent is given or refused. If a guardian refuses to consent to a screening, ask whether the guardian has concerns or questions they want addressed. Where appropriate, offer additional information about the screening’s benefits.  
Understand and accommodate the person’s needs
•	People with mobility challenges may need accessible screening facilities, likes those listed in the Mammography Access Project: http://massmammography.com/aboutus.php

Training & Curriculum Resources

DDS Preventive Health Screenings Computer-based Training is an online course for direct support professionals, house managers, service coordinators, and others about preventive health and the importance of screenings. The course introduces the DDS screening guidelines and emphasizes tools for effective advocacy at the annual physical. Coming Spring 2012!

Advocates, Inc. Going to the Doctor is a 22 minute video presentation  which illustrates ways doctors, individuals and direct care staff can work together to maximize the effectiveness and quality of an individual’s visit to the to the  health care provider.
http://www.advocatesinc.org/userfiles/GTTDBrochure09.pdf

RRI “Making the Connection” DVD trains staff on recognizing signs and symptoms of medical issues, preparing for an effective  health care provider visit, completing required documentation, and administering medication according to the MAP. http://www.rehabresourcesinc.org/PDF/dvdbrochure.pdf

Fluoroscopy Van

Electronic DDS Health Care Records were analyzed for the frequency of preventive health screenings for adults served by DDS. This analysis only includes adults who have a healthcare record in DDS’s electronic systems. Almost all adults living in DDS Residences are included.  A portion of people living in Non-DDS Residences and people living independently, or living at home with their family, are included.  

Data is compared to the 2008-2009 National Core Indicators (NCI) Survey in Massachusetts in which consumers and families are interviewed about outcomes related to health and the quality of state services and supports. 

Analysis of Preventative Screening Rates
Real Data from MORs reported through HCSIS to DDS in FY’09

Description	Annual Physical	Dental Exam	Influenza  Immunization	Mammogram	Colon- or Sigmoidoscopy	
	1+ exam 2010 – 2011; all adults	1+ exam 2010 – 2011; all adults	1+ immunization 2010 – 2011; 
all adults	1+ mammogram 2010-2011; women age 50-69 	Ever received; adults 50-80 yrs	
DDS Target for Adults w/ ID	100%	100%	Close to 100%	70%-95%*	70%-95%*	
Residential Supports	
DDS-funded 	85%	83%	67%	56%	56%	
NCI 	92%	88%	72%	71%
(women age 40+)	26%
(age 50+)	
Non-DDS 	59%	56%	36%	31%	44%	
Own Home/ Family	
MA	37%	33%	20%	34%	38%	
NCI 	81%	73%	54%	72%
(women age 40+)	22%
(age 50+)	
Notes	Recommended to help detect important changes in health status. 	DDS recommends adults receive dental exams at least every 6 months	All adults except those with allergies to the vaccine should be immunized against  influenza	*Preventive screening is not indicated for some women (i.e. those physically unable or with history of breast cancer) 	*Screening may not be appropriate for all people	

The percent of adults receiving health and dental exams in Residential Supports is generally high (83-92%).  A smaller percentage of adults living in Non-DDS settings (56 -59%), and adults living in their own home or with their family (37-81%) receive regular physical and dental exams.

Analyses conducted by:
Center for Developmental Disabilities 
Evaluation and Research (CDDER), 
E.K. Shriver Center, UMass Medical School

For more information on preventive screenings contact: 
Sharon Oxx, RN, CDDN, Director of Health Services, DDS
 Sharon.Oxx@state.ma.us