Disability care

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

In Australia, approximately 4.4 million people or 18% of the population have disability.1 Disability is a broad term that refers to impairments, activity limitations and restrictions that impact an individual’s ability to participate in society on an equal basis with others.1 Twenty-three per cent have a mental or behavioural disorder as their primary disability.1 Studies show that the prevalence of disability in Aboriginal and Torres Strait Islander peoples is twice that of the non-Indigenous population, although there are some data collection gaps in terms of methodology.2,3 The participation rates of Aboriginal and Torres Strait Islander peoples in disability services remains lower than the reported prevalence.4 Almost 43% of people aged 15–64 years with disability rely on a government payment as their main source of income and 53% are participating in the labour force.1

People with disability have a higher burden of poor health outcomes and risk factors. In a national survey of self-reported outcomes, 32% of participants with disability reported high levels of psychological distress compared to 8% of the participants without disability.1 People with disability have much higher rates of obesity, hypertension and smoking and lower rates of sufficient physical activity when compared to people without disability.1,5

People with disability experience higher rates of health inequity, abuse and discrimination, as evidenced by the Royal Commission into Violence, Abuse, Neglect, and Exploitation of People with Disability, established in 2019. Across their lifespan, twice as many people with disability reported experiencing physical violence, sexual violence, intimate partner violence, emotional abuse and/or stalking compared to their counterparts without disability.6 People with intellectual disability are markedly over-represented in preventable hospitalisations for epilepsy and convulsions as well as for vaccine preventable conditions such as influenza and pneumococcal disease.7 Patients with disability in regional and remote areas likely face greater hardships with regards to access to appropriate health services.

General practitioners (GPs) play an essential role in disability care, both in terms of looking after the health of patients with disability, but also in terms of being their advocates while navigating an increasingly fragmented and complex health system. Screening children early for signs of developmental delay in primary care is crucial to linking paediatric patients with allied health interventions that can change the trajectory of their development and potential disability. Screening for and managing metabolic risk factors for patients with disability becomes even more important considering the higher burden of chronic disease they experience.

GPs are the primary physicians for patients with disability living in residential care, playing a key role in screening for issues including cognitive decline, frailty and signs of abuse, while also advocating for appropriate strategies including falls prevention, management plans for chronic diseases and appropriate behaviour management strategies for patients.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • tailor communication style to effectively interact with patients, their families or carers
1.1.1, 1.1.2, 1.1.3, 1.1.4, 1.1.5, 1.1.6, 1.3.1, AH1.3.1
  • check understanding with the patient, their family or carers and ensure that clinical decisions and treatments are effectively communicated to all those involved in care of the patient
1.1.6, 1.2.1
  • adopt a clinical approach free of discrimination which is holistic and respectful to a patient with disability and their family and/or carers
1.1.1, 1.4.1
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • screen for and recognise signs of developmental delay in paediatric patients to ensure early recognition and referral
2.1.6, 2.1.8
  • screen for any relevant behaviour changes in patients with cognitive disabilities that may indicate underlying health conditions
2.1.6, 2.1.8
  • manage complex chronic conditions and multiple medications in patients with disability
2.1.9, 2.3.2
  • screen for and manage signs of mental health distress
2.1.6, 2.1.8
  • formulate good quality management plans in collaboration with team members for patients with disability who have chronic conditions
2.4.1, 2.4.2, AH2.3.1, RH2.3.1
  • provide a yearly systematic health surveillance which recognises the health vulnerabilities of people with disability
2.1.1, 2.1.2, 2.1.6 AH 2.1.1, RH2.1.1
  • apply safe prescribing practices for psychotropic medications as per guidelines in clinical practice for patients with cognitive/intellectual disability
2.1.8, 2.1.9
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • provide equitable access to healthcare by identifying barriers and taking reasonable measures to overcome them in practice, for example, through telehealth, suitable physical access to the practice, and appropriate practice equipment
RH3.2.1, 3.2.2, 3.2.4
  • screen for risk factors of poor metabolic health and risky behaviours including smoking
3.1.1, 3.1.3
  • screen for cognitive decline, frailty, behavioural disturbances, falls, signs of abuse, and any changes in the support environment which might negatively impact a person’s care
3.2.1, 3.2.2, 3.2.4, AH3.2.1, AH3.2.2, RH3.2.1
  • advocate for falls prevention and behaviour management strategies appropriately in residential care
3.2.2, 3.2.4
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • access local health pathways for ongoing training and education in the care of patients with disability
4.2.1, 4.2.2, RH4.2.3
  • record essential demographic details about a patient with disability within the practice software and perform continuous audits of software recording systems
4.4.2
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • identify appropriate documentation and reporting structures for services that assist patients in accessing care, for example, in the development and maintenance of the NDIS plan
5.2.3
  • ensure the practice can provide information in a format that is suitable for patients with disability, including the visually impaired, functionally illiterate, or those who have English as a subsequent language
5.1.1, 5.2.5
  • explain and obtain informed consent in a manner of shared decision-making when substitute/supporting decision-makers are involved
5.2.1, 5.2.2

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Managing patients with disability can seem complex and challenging, and sometimes it is. But if you use effective communication skills that avoid stigma and discrimination, and spend time building rapport, over time you will see the rewards. The skills you develop will make you a better GP and improve your management of all patients with complex chronic conditions.
  2. Always consider recalls, health checks, and vaccines during any consultation with a patient with disability. Try to spend a couple of minutes making sure your practice software has captured this information. This will make your workflow more efficient.
  3. Take some time to review your local referral pathways and identify allied health professionals and specialists you can ask for advice regarding challenging cases.
  4. If any investigations and/or procedures require a patient to be sedated because of their limited cognition, it is essential you mention this on your referral/clinical handover to your acute care colleagues to prevent this important information being lost in transition.
  5. To learn this contextual unit, take a holistic approach by considering each stage of life as you review the guiding topics and content areas. Also consider the broader biopsychosocial context and environmental factors. By doing this you will avoid thinking about disability from a purely biological model of disease.  

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Disability care

Mark, a 48-year-old regular patient from a residential group home has been brought in by his carers after having a fall yesterday. Mark has severe intellectual disability, epilepsy and a history of disinhibited behavioural disturbances.

Mark is on multiple medications including valproate, levetiracetam, sertraline, risperidone and quetiapine. He has difficulty answering clinical questions correctly and is mostly nonverbal. He is usually quite happy to see you but today appears silent and withdrawn. He limps to your room. Overnight he was quite agitated, and staff gave him stat temazepam as prescribed by another doctor. 

Questions for you to consider Clinical exam assessment area Domains

What communication strategies could you use to take a history and perform a clinical examination?

What issues about consent will you need to consider with Mark?

What assistive technology could you use to communicate with him?

How would you approach this consultation if English was not Mark’s first language?

  1. Communication and consultation skills
1,2,5
 

How would you gather additional information about the fall and subsequent agitation overnight?

How would you arrange investigations? How you would obtain investigations if this was a rural location or an after-hours consultation?

  1. Clinical information gathering and interpretation
2   

How do you identify an acutely unwell patient with impaired communication/cognition?

If Mark were an Aboriginal or Torres Strait Islander, how would your differentials change (eg undiagnosed diabetes or renal disease)?

  1. Making a diagnosis, decision making and reasoning
2

What factors would you consider with regards to Mark in the community versus the emergency department?

If Mark were an Aboriginal or Torres Strait Islander, what specialised services or personnel could you include as part of your management plan?

How do you approach polypharmacy in residential care?

  1. Clinical management and therapeutic reasoning
2   

How would you ensure your prescribed management plan is adhered to by the group home?

If Mark were younger and still living at home, how would you help the family to follow your management plan?

If Mark were younger and planning to remain at home, what are the long-term considerations for both Mark and his carers? How could you support both Mark and his carers?

In the long term, what role would allied health team members play in this situation?

What long-term issues need to be considered as part of Mark’s yearly health assessment (eg falls prevention)?

What are some preventive activities that are important to consider in general practice for patients with disability?

  1. Preventive and population health
1,2,3      
 

Where would you look for information on referral pathways for patients with disability?

Are there broader systems-based changes you could advocate for in this residential group home to improve patient care?

  1. Professionalism
4   

Can your practice software capture information about patients with disability?

How would you ensure recalls for preventive activities are followed through in your software system?

Is your practice ‘disability friendly’ in terms of access, booking of appointments, etc?

  1. General practice systems and regulatory requirement
5   

If consent is appropriately gained but the patient is not particularly compliant, what steps are involved in performing a finger prick glucose test and venesection for bloods?

  1. Procedural skills
2   

How would you access additional support/advice about managing this presentation?

  1. Managing uncertainty
2   

Some patients with disability have limited communication. How would you recognise a significantly ill patient if this were the case?

What modes of clinical handover might be essential? How would this change in a rural location?

How would you ensure Mark is followed up?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Identify three patients from your practice software with disability and audit the notes to check for evidence of consent being documented and appropriate strategies being used to take a history, conduct a physical examination and/or perform investigations. Compare to your own study on the topic.

  • What has been missed? What could be improved? How could you improve your practice in this area?
  • What different types of disabilities have you identified in your patients; for example, physical, intellectual, emotional?

If possible, invite a patient with disability from a residential care home to have a yearly health check/CHAP tool. Identify and use an appropriate template from the resources provided in the learning resources section.

  • Why did you pick this template? How could it help you undertake a health check? What is included?
  • Could you use or adapt this for patients with disability who live at home?

Identify patients from your practice software with disability who are on more than three medications and conduct a medication review. Refer to guidelines for managing polypharmacy, specifically around the risks of prescribing psychotropic medications in patients with disability and/or in residential care. Perform a home medicines review with a pharmacist, if not previously done, and discuss your findings with them.

  • Do all medications have appropriate clinical indications?
  • For the medications that need regular monitoring (eg serum levels or INR), is this being done?
  • Are there any interactions between medications that haven’t been considered?

Audit your clinical software for 10 patients – paediatric and adult – with disability (eg autism spectrum disorder, cerebral palsy) and check if their vaccination status meets current guidelines for vaccination in high-risk populations as per the Australian Immunisation Handbook.

  • Are any patients missing vaccinations?
  • Try to include Aboriginal and Torres Strait Islander patients in your audit – are the guidelines different?
With a supervisor

If any of your supervisors see patients with disability from residential care, review how they identify acutely unwell patients and how they refer them in the local community.

  • What are the issues to identify?
  • What strategies can you learn from your supervisor?

Pick a patient with disability from the clinical software – this could be your patient or your supervisor’s – and identify and discuss the barriers to care for this patient.

  • Do they have financial assistance from the government? Was this difficult to obtain?
  • Have they faced issues around bullying/stigma with regards to their disability? How would you manage this in practice as their doctor and advocate? How often would you specifically ask about this in practice?

If any of your supervisors visit residential group homes, accompany them on a visit and evaluate how management of the consultation differs from one conducted in-practice.

  • What are the key differences?
  • What aspect of assessing a patient in the group home context did you find most challenging?
  • How does your approach to history-taking and physical examination need to be adapted from that in the practice setting?

If any of your patients with disability need a screening procedure or a preventive activity such as a vaccination, ask your supervisor to be present and give you feedback on your ability to get informed consent and conduct the procedure appropriately and safely.  

  • What did your supervisor suggest that you do differently?
In a small group

Role-play a consultation with a patient who has limited cognition/communication and is acutely unwell. As a group, discuss potential issues in gathering information and gaining consent, and consider when to refer a patient to the local emergency department.

  • What communication strategies did you use?
  • How did you identify if the patient was acutely unwell?

As a group, discuss your experiences in identifying developmental delays in children during health checks and vaccination appointments.

  • How did you break the news to parents and manage their expectations?
  • How did you facilitate and ensure follow-up of the issues you identified, and how did you involve allied health and specialists?
  • What strategies can you take from this discussion to use in your own practice?
With a friend or family member

Ask your friend or family member to imagine they are a parent of a newborn diagnosed with cerebral palsy, or a child with severe developmental delays. Ask them what their immediate, short-term, and long-term concerns would be.
This is a helpful resource to use: Rethinking Childhood Disabilities - Happiness vs Healthiness.

  • How could you, as a GP, address these concerns?
  • What sorts of things did they come up with? Is it what you expected?
  • How could you develop skills to manage these things?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

Caring for patients with disability

The term disability refers to physical, sensory, intellectual, and psychological impairments that cause some level of restriction or limitation to activities or to an individual’s ability to participate in everyday activities.

  • Understand the aetiology of common disabilities encountered in general practice:
    • cerebral palsy
    • spina bifida
    • autism spectrum disorder
    • chromosomal disorders; for example, Down’s syndrome, Di George syndrome
    • attention deficit hyperactivity disorder (ADHD)
    • neurological diseases such as multiple sclerosis (MS)
    • neurodegenerative diseases such as Alzheimer’s, Parkinson’s, and Huntington’s diseases
    • traumatic brain injury and spinal injuries.
  • At every stage of caring for a patient with a disability understand and define the medico-legal implications of appropriate consent to treatment and to undertake preventive activities, specifically:
    • vaccination of high-risk populations
    • healthy lifestyle interventions; including diet, exercise and smoking cessation
    • reducing and/or preventing cardiometabolic risk factors
    • screening for carer stress
    • developing management plans, including managing sick days, for chronic conditions; such as asthma and type 2 diabetes
    • ensuring screening is always up to date; including cervical cytology, faecal occult blood test (FOBT), breast screening and screening for diabetes.
Disability in childhood
  • Through a detailed history, examination and assessment, screen for childhood congenital, chromosomal or developmental disabilities:
    • during developmental assessments at the newborn stage and at every vaccination appointment
    • during antenatal screening, as appropriate, and monitor for physical and congenital disabilities in pre-term babies.
  • Understand the importance of early intervention of allied health for certain developmental delays.
  •  Formulate management plans and referrals to the National Disability Insurance Scheme (NDIS).
Disability in adolescents and young adults
  • Screen for and manage mental health issues; including depression, anxiety and/or psychosis.
  • Screen for and manage risk-taking behaviour around drugs, alcohol and sexual relationships.
  • Consider the impact of the young person’s disability on education and employment opportunities.
  • Consider and manage the impact of the person’s disability on their ability to drive a car or motorcycle.
  • Consider issues around contraceptive use, consent, screening for sexually transmissible infections (STIs) and sexual/gender identity, if sexually active, and consider the impact of the young person’s medication(s) on this.
  • Facilitate transition into adult services for the young person’s disability.
Disability in adults – congenital or acquired
  • Understand the importance of specialised support services.
  • Review referral pathways for respite and residential care.
  • Screen for carer stress.
  • Consider and help manage the impact of the person’s disability on accessibility to transport, their sexual activity and overall wellbeing.
  • Screen for mental health issues; including depression and/or anxiety and be able to discuss the stigma the person may face in the community.
  • Consider and help manage the person’s access to housing, employment and funding for services.
  • If the condition is terminal, consider advance care planning or early utilisation of palliative care services.
  • Screen for polypharmacy and understand the issues around safe prescribing of psychotropic medication to patients with intellectual disability.
  • Competently conduct a yearly health assessment.
  • Screen for the ability to perform activities of daily living.
  • Screen for signs of cognitive decline through screening tools such as Mini-Mental State Examination (MMSE) or Addenbrooke’s Cognitive Examination-III (ACE-III), as well as through obtaining a history from carers/family.
  • Be aware of a decline in the person’s self-care skills, memory, recognition of others, and ability to communicate and access the community.
  • Consider the impact of the person’s disability/impaired cognition on their ability to drive.
  • Be familiar with the Geriatric Depression Scale (GDS) and consider screening for mental health disorders; including depression and anxiety.
  • Investigate the impact of isolation on the person’s mood and daily functioning.
  • Be familiar with falls prevention and managing frailty.
  • Learn about advance care directives, power of attorney legislation, medical decision-making and palliative care support for end-of-life planning.
Caring for patients with disability in residential care
  • Depending on the person’s age and cognition level, communicate with them appropriately and gather information from multiple sources; including carers and family members regarding health complaints.
  • Understand the importance of appropriate communication, both verbal and written, between health professionals working at the facility and ensure management plans are clear and actionable with appropriate safety netting and follow-up.
  • Recognise and manage polypharmacy, especially in the context of after-hours prescribing.
  • Understand the principles of falls prevention.
  • Understand and advocate for behavioural management strategies instead of psychotropic medications, wherever possible.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
A summary of the complexity of looking after children in out-of-home care, with therapeutic recommendations with an evidence base, and helpful tables. The potential underlying mental health and social issues in undiagnosed autism, particularly for females. A good overview of the clinical issues for GPs supporting families dealing with autism.
Textbooks
An extensive section covering all topics within disability care in an Australian context.
  • Developmental disability [published 2021 Mar]. In: Therapeutic Guidelines [digital]. Melbourne: Therapeutic Guidelines Limited; 2021 Mar.
Online resources
Podcasts that provide evidence for responsible prescribing and highlight alternatives in terms of advocacy and behavioural strategies. The CHAP yearly assessment tools conducted by GPs for patients in group homes across Australia. An important resource for GPs with patients with disability applying for the NDIS. A resource about the importance of understanding the stigma and abuse vulnerable populations face and providing non-judgemental and holistic care to patients with disability. A comprehensive toolkit and training in clinical and medico-legal complexities of managing patients with an intellectual disability.
Learning activities
An excellent online course to learn about the high prevalence of metabolic risk factors in patients with intellectual disability. Increase your knowledge and awareness about barriers to accessing mainstream healthcare for people with disabilities. Excellent resources for both clinical learning and exam preparation.
  • The Royal Australian College of General Practitioners, gplearning activities: 
    • How to recognise confusion in the elderly both in residential care and in the community, how to manage it, and the GP’s ethical and legal role.
    • Acute confusion in the elderly – causes and management implications. Comprehensive Health Assessment Program template and information.
    • Care of people with cerebral palsy in general practice MCQs.
A comprehensive overview of screening for and diagnosing development delays that may be due to autism.
  • Autism spectrum disorder – Screening, diagnosis and intervention.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/disability-care 30/06/2022