Improving Processes in Health Risk Screening Among Staff Serving Adults with ID
By Stephanie Rancich DNP, RN, CNL, Bridget O’Brien DNP, APRN, FNP-BC, Olanrewaju Abayomi BSN, RN, Sarah H. Ailey PhD, RN, CNE FAAN
Abstract
People with intellectual disabilities and developmental disabilities on average die younger and have more health problems than people without IDD.1,2 Especially if the level of IDD is more severe, the person with IDD may not be able to verbalize health problems and is reliant on others to recognize their symptoms, leading to delays in treatment and poor outcomes. The Health Risk Screening Tool (HRST) that includes a Health Care Level (HCL) scoring system, is meant to be used to improve recognition of health problems and improve outcomes.3 This article describes a quality improvement initiative aimed at enhancing the awareness, understanding, and skills of staff working in residential settings for people with IDD in the use of the HRST within a non-profit agency providing residential services to over 100 adults with IDD in a city in Illinois. A staff survey revealed significant gaps in awareness and understanding of the HRST. The project was guided by the Kellogg Logic Model and included education to improve awareness and understanding about the HRST targeted to specific levels of staff and an updated workflow plan of responsibilities in using the HRST. The initiative achieved high satisfaction among participants. Results also indicated the need for ongoing monitoring and assisting with implementation of the workflow plan with management support to ensure that the HRST is used as intended.
Introduction
The HRST is a tool used to screen for risk of health destabilization of people with intellectual and developmental disabilities and to subsequently provide tools and training to support the health needs of screened individuals. The HRST was initially developed in 1992, in part due to a federal court case Homeward Bound vs. Hissom Memorial Center, which aimed to protect the health and safety of people with IDD with significant health support needs who were transitioning from institution settings to community-based settings. The HRST provides screening on a person’s risk of health destabilization for determining which persons required specific health support plans and information on what should be in the plans.4 The HRST generates a Health Care Level (HCL) of 1-6 based on 22 items related across five domains; functional status (e.g., eating, ambulation), behavioral health (e.g., aggression, self-abuse), physiology (e.g., anti-epileptic use, skin integrity), safety (e.g., falls, injuries), and service utilization (e.g., ER visits, hospitalizations). The HRST is now in use in 26 states and is a web-based application. Illinois provides funding for the HRST web-based application for each person living in a Community Integrated Living Arrangement and requires that providers conduct HRST screening for the persons with IDD at least once per year and within 14 days of health changes.
Staff filling out the HRST must be at a Qualified Intellectual Disability Professional (QIDP) level, have access to health records, and know the person well. Agency providers must designate a gatekeeper responsible for communication with HRST site and personnel and for registering HRST raters and clinical reviewers in the HRST system. Clinical reviewers must be Registered Nurses. For persons with HRST scores ≥ 3, a Registered Nurse must complete a clinical review within 14 days to evaluate the validity of the HCL score and develop individual support plans,5 noting that the HRST program site automatically provides suggestions for services and staff training that can be used in the individual’s plan.3 Other than the gatekeeper, there are no specific requirements for oversight.
“The overwhelmingly positive feedback from trained staff suggests that with sustained support, broader implementation could improve recognition of potential health problems and initiation of support plans with people with IDD in residential settings.”
This article shares the story of a quality improvement initiative at a non-profit agency in a city in Illinois. The agency provides housing and support services to over 100 adults with IDD. The project aimed to increase staff awareness, understanding, and skills and to improve processes in using the HRST as part of improving proactive, person-centered care.
A pre-project survey revealed that 45% of frontline staff were unaware of the HRST, and 47% did not understand what an HCL score represented and steps to be taken related to an HCL score.
Methods
Using the Kellogg Logic Model,6 the project team developed a structured plan to improve staff HRST awareness, understanding, and skills and improve HRST implementation processes. Key objectives included: 1) Educating 100% of nursing staff and 75% of frontline staff on the HRST scoring system with education specific to the level of staff; 2) Updating and standardizing the HRST workflow processes; 3) Ensuring nurse-initiated communication forms for all individuals with HCL ≥3 with placement of forms in HRST binders by program coordinators. In addition, six individuals with HCL ≥3 were selected for piloting the workflow implementation.
Objectives
Outcome objectives included: 1) Participation by 100% of nurses and 75% of other staff in HRST training; 2) A 25% increase in staff knowledge of the HRST tool and HCLs based on pre- and post-surveys; 3) Implementation of workflow processes and use of communication form for 100% in the pilot; 4) Staff satisfaction of 80% with the new workflow.
Results
Sixty staff members participated in educational sessions on the HRST. All nurses (goal met) and 67% (below target) of frontline staff received training on the HRST and the new workflow process. Awareness and understanding about the HRST increased by 18% and about HCLs specifically by 11%. Nurses initiated forms for 5 of the 6 (83%) individuals selected for the pilot of the workflow process pilot. However, at the time of evaluation, program coordinators had placed communication forms in binders for only 2 of the 6. Among survey respondents, 100% reported satisfaction with the program.
Facilitators and barriers
Facilitators for the quality improvement program included management support and recognition among staff of the importance of identifying health problems among people with IDD. A major barrier was high staff turnover that delayed implementation and the continuity of the project.
Conclusion
Despite barriers, the quality improvement project demonstrated that structured education and workflow process design can improve staff awareness, understanding, and satisfaction with the HRST. The overwhelmingly positive feedback from trained staff suggests that with sustained support, broader implementation could improve recognition of potential health problems and initiation of support plans with people with IDD in residential settings. Considering ongoing staff turnover, regular training in health risk screening for all staff in residential service agencies is important. The use of structured workflow plans with accountability is likely useful. Tailored training and clear communication protocols can enhance staff awareness, understanding, skills, and accountability in health risk screening. Agencies should allocate resources for ongoing education and implementation support. Policymakers may consider incentivizing specific efforts for improved screening and individual health risk plans.
References
1. Cooper SA, Allan L, Greenlaw N, McSkimming P, Jasilek A, Henderson A, McCowan C, Kinnear D, Melville C. Rates, causes, place and predictors of mortality in adults with intellectual disabilities with and without Down syndrome: cohort study with record linkage. BMJ Open. 2020 May 17;10(5):e036465. doi: 10.1136/bmjopen-2019-036465. PMID: 32423940; PMCID: PMC7239521.
2. Liao, P., Vajdic, C., Trollor, J., & Reppermund, S. (2021). Prevalence and incidence of physical health conditions in people with intellectual disability - a systematic review. PloS one, 16(8), e0256294. https://doi.org/10.1371/journal.pone.0256294
3. IntellectAbility (nd). What is the HRST https://replacingrisk.com/health-risk-screening-tool-overview/
4. IntellectAbility (nd). The IntellectAbility story. https://replacingrisk.com/about/#:~:text
5. Illinois Department of Human Service. Health Risk Screening Tool (Replaces DD.24.005) https://www.dhs.state.il.us/page.aspx?item=166902
6. Kellogg, W. K. (2004). WK Kellogg Foundation Logic Model Development Guide. Battle Creek, MI: WK Kellogg Foundation.