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Comprehensive Health Assessment

NDIS Practice Standard 3: Provision of Support #

1.0 Purpose #

Participants are at a high risk of poor health, chronic disease and premature death from potentially preventable causes. Completing a regular comprehensive health assessment for participants improves detection of health needs, enables active management of those needs, and significantly reduces health risks and poor health outcomes.

Participants have a right to maintain optimal physical, oral and mental health. iSeekSupport must monitor participant health, safety and wellbeing, support participants to maintain their health and access appropriate health services.

2.0 Scope #

This policy and procedure guide all staff who develop and implement support plans.

3.0 Policy #

All staff must follow the NDIS Code of Conduct and undertake the following:

  • Act with respect for individual rights to freedom of expression, self-determination and decision-making following applicable laws and conventions
  • Provide supports and services safely and competently with care and skill
  • Promptly take steps to raise and act on matters that may impact the quality and safety of participants’ support and services.

iSeekSupport is committed to demonstrating compliance with the National Disability Insurance Scheme (Provider Registration and Practice Standards) Rules 2018. This policy is linked to the NDIS Practice Standards, including:

  • Support planning: participants are actively involved in the development of their support plans. Support plans reflect participant needs, requirements, preferences, strengths, and goals and are regularly reviewed.
  • Access to supports: participants access the most appropriate supports that meet their needs, goals and preferences.
  • Responsive Support Provision: participants access responsive, timely, competent and appropriate supports to meet their needs, desired outcomes and goals.
  • Incident Management: participants are safeguarded by our incident management system, ensuring that incidents are acknowledged, responded to, well-managed and part of our continuous improvement regime.
  • Information Management: participants’ information is managed to ensure that it is identifiable, accurately recorded, current and confidential, with information being easily accessible to the participant and appropriately utilised by relevant workers

4.0 Procedure #

4.1 Risks of health problems for people with disability #

Participants are at risk of poor health and conditions that are not yet diagnosed and are at an increased risk of potentially avoidable deaths. Many people were experiencing multiple health problems at the time of death, including epilepsy and poor nutritional, oral and mental health.

Risks are more likely for participants due to a combination of the following:

  • Some participants may be unable to communicate when they feel unwell or experience pain and may communicate in ways that are specific to them and not well understood by others
  • A person’s symptoms or behaviours are attributed to their disability, and as a result, they do not receive appropriate health assessments or treatments
  • A mix of individual, medical, communication and social problems due to disability, health conditions that run in the family, poor nutrition, inappropriate accommodation, abuse and neglect, homelessness, inadequate preventative health care or treatment
  • Lifestyle factors, such as obesity, physical inactivity, isolation, smoking and alcohol intake.

4.2 Addressing health risks #

Health risks can be addressed through the following interventions.

4.2.1 Identify symptoms early #

Staff must be informed of and know how to communicate with each participant to develop trust, informing staff when unwell. Early identification of changes in a participant’s health and wellbeing means that the participant can access medical services earlier and prevent illness from progressing. It is important to know the participant’s usual health so that changes can be observed. Obvious changes would include:

  • Unexpected weight loss or gain,
  • A sudden change in eating habits,
  • Sudden breathlessness,
  • A drop in activity due to fatigue,
  • Expressions of pain and apparent sudden changes in behaviour.

4.2.2 Promptly visit a general practitioner (GP) #

Staff must inform CEO or their managers promptly of any changes in their usual health so the participant can access a GP when unwell.

4.2.3 Undertake a regular comprehensive health assessment resulting in a healthcare plan #

A comprehensive health assessment involves the participant and GP discussing and reviewing the participant’s medical history, current health problems, medications and any lifestyle risks. Regular comprehensive health assessments have been shown to prevent illness and maintain the health and wellbeing of participants. These outcomes result from identifying unmet health needs, preventing disease, engaging in regular health care and improving communication with the GP.

Based on health information and physical examination, the GP will recommend what the participant requires for good health and wellbeing. The GP will also recommend and refer the participant for appropriate preventative health care such as regular screening for serious conditions. For example:

  • Skin cancer checks;
  • Breast or bowel cancer screening.

The participant, GP and iSeekSupport can then develop a healthcare plan based on the recommendations from the comprehensive health assessment.

4.2.4 Be proactive with chronic illness #

Both the medical practitioner and the participant can proactively manage chronic illness by monitoring symptoms that might indicate a change to health status, making changes to lifestyle if needed, attending regular medical appointments, and managing chronic illness and disease, for example, regular blood tests for diabetes, blood pressure monitoring and medication reviews.

iSeekSupport will work with all parties to assist the participant in attending medical appointments and support them in any processes that are required as part of being proactive.

4.3 Supporting participants #

iSeekSupport will monitor participants’ health, safety and wellbeing, support participants to maintain their health and access appropriate health services and support the participant to access annual comprehensive health assessments.

4.3.1 Support participants to understand their own health needs and to make informed health decisions #

iSeekSupport will:

  • Talk to participants about their health and develop a healthcare plan
  • Support participant’s understanding of health through the provision of accessible health information; see the resource section below for ideas and tools
  • Facilitate informed decision making regarding health care using the participant’s preferred communication methods. Where appropriate, involve the participant’s family, independent support person or guardian in the decision-making process.

4.3.2. Support participants to communicate with healthcare providers #

If required, work with a speech pathologist to create or expand a personal communication system for the participant to have a way of saying when they are unwell, including:

  • Words/signs/symbols that can describe pain, nausea and fever, anxiety, emotional distress.
  • Determine the level of support the participant requires to make and attend a medical appointment with the GP or to have blood tests, scans or other procedures.
  • Support participants to build a relationship with their GP through regular contact.
  • Assist the participant to use their preferred method of communication with the GP or healthcare provider during appointments.

4.3.3 Support participants to access healthcare #

iSeekSupport will:

  • Encourage the participant to let you know if they do not feel well using their preferred communication methods
  • Have a good understanding of the participant’s health and potential symptoms to watch out for; this includes when there are changed behaviours or function
  • Support the participant to attend the GP if they are unwell.
  • Support participants with chronic illness to understand their symptoms, treatment plans, recommended lifestyle changes, and regularly visit their GP
  • Refer to Practice Alert: Transitions of care between disability services and hospitals to assist with hospitalisation.

4.3.4 Support participants to access preventative healthcare #

iSeekSupport will:

  • Support the participant to follow their healthcare plan
  • Undertake preventative healthcare such as regular medical and dental check-ups in between annual comprehensive health assessments
  • Refer to The Practice Alert: Lifestyle Risk Factors to improve health outcomes.

4.3.5 Plan and support participant’s health appointments #

iSeekSupport will

  • Support the participant to make a GP appointment or, with consent, make the appointment on their behalf
  • Arrange transport, telehealth facilities, parking if required. Workers should familiarise themselves with the health facility/GP office to support the participant’s access to appointments,
  • Consider if it will be a difficult day for the participant, are there likely to be long waiting times, will they experience fatigue, and how is that best managed?
  • Communicate with the GP about the participant’s triggers for distress, communication aids or physical access requirements
  • Time the health assessment on a day when it is likely to less busy in the general practice. Talk to the general practice and make a time that works for both the participant and the GP.

4.3.6 Maintain participant health and medical information #

iSeekSupport will:

  • Ensure relevant support staff have access to important health information, including current health problems, medications, allergies, adverse effects from medications, and reports from medical specialists and allied health professionals
  • Ensure that a record of each visit to a health professional is kept in the participant’s file, and this is made available each time the participant sees a health professional
  • Ensure that any health care recommendations are documented and actioned following appointments with health care professionals
  • Implement regular and timely reviews are undertaken on participant medical and health records, and in time for comprehensive health assessments (at least annually or more regularly due to changes in health)
  • Before a comprehensive health assessment (at least annually), a full review of participant records should be undertaken to identify concerns, risks, or any information about potentially undiagnosed symptoms that may not have been followed up
  • Maintain participants’ health records in line with privacy and confidentiality requirements.

iSeekSupport Policy and Procedure – Published 09.02.2022 #

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