SEL AHC Training 6th Oct 23

Learning Disability Annual Health Check

SEL ICS Learning Disability and Autism Specialist Prescribing Advisors Thomas lee, Trang Dinh, Ashika Patel

Community LD Team (CLDT) Complex Physical Health (CPH) nurse and other Allied HCPs Liz McGrath Lead Nurse , CLDT, Oxleas

Agenda

• Setting the scene? What do we know so far?
• Annual Health Checks
• What should an AHC look like in practice?
• Case study (Pharmacist)
• Community Learning Disability Team role and function
• Case study (CLDT)

Question

Question

Setting the scene: What do we know so far?

LeDeR 2021-2022 annual report

Setting the scene: What do we know so far?

Setting the scene: What do we know so far?

Non-Verbal patient?

Constipation

20-50% prevalence in the LD population, 10% in general population

Dying for a Poo https://bowelinterestgroup.co.uk/news/dying-for-a-poo/

Annual Health Checks

• 14+ years old and on Learning Disabilities Register
• Make a significant impact on improving health outcomes and reducing inequalities.
• Identify new health conditions- earlier detection and management of physical and mental health conditions,
• Timely and effective treatment for more urgent and serious medical conditions

Annual Health Checks

Annual Health Checks

Annual Health Checks

Consent - Includes coding for:

• Capacity Assessment For Information Sharing
• Consent - For Electronic Record Sharing

- For SCR with Additional Information - To Share Data with Specified 3rd Party - To Share Data with 3rd Party Details plus free text Advice regarding managing patients’ consent for Summary Care Record with Additional Information can be found here: https://digital.nhs.uk/summary-care-records/additional-information

Remember to record carer demographic details and offer Carer Health Check & Flu Immunisation where appropriate

• Emergency contact details
• Patient Support / accommodation plus free text

Record any recent or planned moves

• Personal Status
• Employment

Support & Patient Information Includes coding for:

• Under care of social services
• Social worker involved
• Keyworker Details plus free text

Remember to include any specialist teams e.g. Learning Disability Team

• Has A Carer - Carer's details free text

Vision - guidance suggests a person should see an optometrist at least every two years

• Eyesight
• Seen by optometrist - Seeability https://www.seeability.org/optometrists

Hearing

• Hearing
• Wax in ear
• Seen by audiologist

Dental - guidance suggests the person should see a dentist at least annually

• Seen by dentist

Additional Support Needs and Reasonable Adjustments

• Consider time, environment, communication & additional health needs
• Remember Accessible Information Standards
• Include this information in all referrals

Includes coding for:

• Reasonable Adjustment
• Seen by Speech & Language Therapist
• Communication – Level
• Assistance
• Details plus free text

Specific Syndrome Check - Includes coding for

• Specific Syndrome Comments plus free text
• Down's Syndrome Diagnosis only appears if the patient has a Downs syndrome diagnosis
• Congenital Heart Disease (P68 Congenital Heart Disease)

Consider specific interventions indicated by syndromes present. If the patient has Down's syndrome please ask other family members, carers or care workers (as appropriate) about any changes that might suggest the need for an assessment of dementia such as:

• Change in behaviour
• Forgetful

Medication Review - Including STOMP

• Consider reduction in antipsychotic medication especially if prescribed for behaviour management or where there is no diagnosis of psychosis
• Consider additional drug monitoring e.g. Anti-epileptic drug monitoring.
• Consider implementing Cardio-metabolic pathway (see RCGP Step by Step guide)
• Consider review by pharmacist - Medication Review

Includes coding for:

• Season Influenza Vaccination
• Pneumococcal Vaccination

Pneumococcal Vaccination as guided by Green Book indications

• Hepatitis B Vaccination

Hepatitis B is indicated if patient lives in shared accommodation. A high risk of hepatitis 'B' has been seen in the population of individuals with learning disability living in residential accommodation.

• HPV
• MMR
• Allergies

Immunisations & Allergies People with learning disability should have the same regimes as others and the same contraindications apply, except for the following, which all people with a learning disability are entitled to.

If the patient is immobile, consider postural care needs – see RCGP Step by Step Guide

Lifestyle & Health Promotion – Don’t forget to code Includes coding for:

• Patient Diet - Patient advised re diet
• Exercise Level - Patient advised re exercise
• Smoking Status - Smoking cessation advice
• Alcohol Consumption - Patient advised about alcohol
• Substance misuse - Lifestyle advice regarding drug misuse

Annual Health Checks

The following headings will appear and will be self-populating from the record if blood tests have been done

• Hb1Ac
• Serum Cholesterol
• Full Blood Count
• Serum HDL cholesterol level
• Thyroid Function - Test Regular thyroid function test required for all patients with Downs Syndrome.
• Urea & Electrolytes
• Liver Function Test
• Urine Dipstick

Latest Test Results Consider clinically relevant blood tests according to current guidelines. Consider point of care testing as appropriate – see RCGP Step by Step Guide Remember also:

• Lithium and anti-epilepsy drug levels
• Vitamin D if on AED
• FSH in prolonger amenorrhoea
• PSA (if indicated)
• CRP (if indicated)
• Stool H pylori antigen (if indicated)

Safeguarding Try to take a moment alone with patient and ask if they are being hurt by anyone. Includes coding for:

• Safeguarding Concerns
• Safeguarding Concerns Comments plus free text
• Is the person subject to DOLS

Includes coding for:

• Child Status (Looked after child) - Child Support
• Education, Health & Care Plan-Based Care
• Education
• Under Care Of (e.g. Paediatrician, Mental Health team etc.)
• Child in transition to adult service

14 -17 Years Only Education, Health & Care Plan (EHC) was formerly known as Statement of Special Educational Needs (SEN) – see RCGP Step by Step guide

Annual Health Checks: What does good look like?

• Who is to conduct physical health check examination
• Easy read leaflet invitation
• Reception team communication + reasonable adjustment
• Duration of appointment

Holistic Care: BP, BMI, MSK, Dentistry, Optometry, vaccination and immunisation, cancer screening, smear test, medication adherence, physical activities, housing, respite.

• Risk awareness
• Referrals and signposting
• Mental capacity act - fluctuating capacity (e.g. mental health / dementia)

Case Study

• Patient with a mild LD, has capacity and lives with wife
• Self-admin medications prompted by wife 4 times a day
• Forgetful and misses his meds when wife is away
• No other friends or family available to support

How do we support medication adherence ?

Case Study

• Wife has been admitted to hospital and patient is left at home
• Dementia Dx has now been confirmed and patient has been determined as having fluctuating capacity around medications and other medical procedures.
• Patient forgets to take his medications

How do we support medication adherence ?

Case Study

• Dementia has worsened, and now patient now lacks capacity
• Key workers comes in 4 times a day to support medication admin
• Patient refuses his medication occasionally due to taste and swallowing issue.
• Some of the medications are for BP, epilepsy.
• Previous Hx of hospital admission due to seizures when patient forgot to take anti-epileptic

How do we support medication adherence ?

Question

Question

LDAprescribingteam@selondonics.nhs.uk

We’re kindWe’re fair We listen We care

Greenwich Community Learning Disability Nurses Complex Physical Health

• Liz McGrath liz.mcgrath1@nhs.net 07342 086912

• Louise Stockdale, louise.stockdale@nhs.net
• Amanda Rwatangabo, Amanda.rwatangabo@nhs.net

• Marina Pinhorn, marina.pinhorn@nhs.net

• Fiona Pascall, specialist support worker.
• Erica Paller, trainee nursing associate.

• Jenny Sentongo, Jennifer.sentongo@nhs.net Hospital liaison nurse.
• Reena Dhaligadoo, Reena.dhaligadoo@nhs.net Hospital liaison nursing associate.

Community Learning Disability Team CLDT Greenwich

CLDT 2nd Floor The Woolwich Centre 35 Wellington Street Woolwich SE18 6HQ 0208 921 4860.

Integrated team:

• MH/LD nursing
• Psychiatry
• Social workers/assessment officers
• Psychology
• SALT
• OT
• Physio
• SPA/Duty
• Preparing for Adulthood

Eligibility Criteria:

Greenwich CLDT is a specialist service for people with a learning disability and operates criteria for a referral to the service: A learning disability is defined by the Department of Health as:

• Significant reduced ability to understand new or complex information and to learn new skills.
• With reduced ability to cope independently.
• Which started before adulthood (before 18th birthday)

(All 3 must be present to accept referral).

People we do not work with:

• Those with impaired ability as a result of enduring mental illness even though they may be functioning in the Learning Disability range.

• An autistic spectrum condition or other social communication disorder when the person does not also have a significant Learning Disability.

• Brain damage acquired during adulthood (over 18).
• People with a learning difficulty (e.g. dyslexia) without a Learning Disability.

Referral process/Eligibility:

1) Eligibility request received. 2) Discussed at the weekly MDT referrals meeting. 3) If enough evidence of a learning disability they will go on an eligibility waiting list. Will request more evidence if needed. If they have a LD such as a diagnosis of downsyndrome they will automatically be added to our register. 4) An appointment will be booked for the person to be assessed for eligibility by a health and social care worker in the team. 5) If accepted a social care review will take place, and if health input is needed it will be decided which discipline is best placed to work with the person. 6) If not accepted they will be sign posted to another team or signposted to the initial contact team for a needs assessment.

Liz: Complex Physical Health Nursing

• Imminent discharge from hospital/safe discharge.

• Referral for a condition resulting in recent (within 12 months) hospital admission.

• Support with managing medication safely

• 2 week wait – cancer pathway

Louise:

• Support with health condition appointments (including client specific AHCs)

• MCA / BI support

• Epilepsy/Respiratory/Physical Health Pathway

• Advance care planning

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Liz:

Accept referrals to mitigate risk relating to:

• Condition risk assessment/management

• Case specific care coordination

• Health promotion

• Training specific to client
• discharge from hospital

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Clinics/Groups: Liz.

• Memory clinic, set up to diagnose dementia, build a support network around the person and set plans, and review.

• Research Net, is a group for service users interested in research in mental health and learning disability. Projects completed: training delivered to professionals about learning disabilities, schools and bullying.

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Louise:

• Healthy living group, nutrition, shopping choices, healthy recipes, social skills, planning, budgeting.

• No barriers here: an innovative approach to advance care planning for people and communities who experience inequality accessing palliative and end of life care.

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Louise:

• Fun and Fitness: collaboratively working with the local gym to offer bespoke classes, health observations.

• Exempla work: Review of LD registers in GP practices.

• My Health clinic: Health reviews.
• Exemplar work.

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CPH nursing case example 1

• CF is open to SaLT for a dysphagia review and care plan. During the home visit I asked about her general health and Mum mentioned that she is trying to get some help around her periods, as they are very heavy and come frequently. Mum would like to have some help and advice from the Nursing Team to investigate this problem.

Nursing actions: Mobile clinic/full nursing assessment:

• Menstruation, vaginal discharge- liaised with GP, referral to gynae, swab for discharge.
• Insomnia, trailing new medication.
• Specialist dental referral completed.
• AHC, booked.
• Weight, liaising with GP, referral to surgeons for PEG tube to be replaced.

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Case example 2

• JM is open to CPH nursing mainly for support at health appointments.
• She has a mild Learning disability and lives independently in her flat.
• JM has had breast cancer surgery and radiotherapy.
• Annual mammograms
• Cardiac investigations.
• Liver and thyroid ultrasound scans.
• Treatment for basal cell carcinoma on her nose.
• Despite all the above, JM is living a healthy and fulfilling life.

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Case example 3

• DP is a 57-year-old man with a mild learning disability.
• DP has been married for 23 years. He lives with his wife in a flat.
• Obesity: BMI 63.4 in May 2021, DMT2, chronic leg ulcers.
• Medications in dossette boxes.
• Mobility problems due to his weight: DP has not been out for a walk since 2019.
• Lost 43 kg to be considered for the surgery.

NURSING REFERRAL:

• Open to CPH nursing for support with his bariatric surgery (gastric sleeve).
• Hospital appointments: transport, capacity, reasonable adjustments.
• MDT: Bariatric Consultant (Surgeon), Dietitian, Bariatric Nurse, Anaesthetists, Pharmacists, Ward Nurses, GP, Social Care, Physiotherapists, District Nurses, CLDT.
• Endoscopy. Bariatric surgery cancelled several times. Liver shrinkage diet.
• Post-operative care: diet, medications, personal care, appointments.
• Bariatric surgery was successful. DP is making good recovery. Current BMI 46. Keeps losing weight.

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MENCAP GREENWICH new service:

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Questions

Thank you, any questions?

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