Transforming Clinical Care
For Individuals with Intellectual and Developmental Disabilities: Lessons from the Texas State Supported Living Center System
By Ashton Wickramasinghe, MD, FACP
Summary: Dr. Ashton Wickramasinghe describes how Texas’ State Supported Living Centers developed a statewide strategy to improve healthcare for people with intellectual and developmental disabilities. The approach is built on four pillars: stronger clinical communication, expanded IDD-focused medical education, rigorous quality improvement, and better staff recruitment and retention.
The article highlights initiatives addressing aspiration pneumonia, epilepsy, dementia screening, care transitions, and workforce development while emphasizing a broader goal: specialized IDD expertise should not remain confined to institutional settings. Lessons developed within the SSLC system can help strengthen person-centered care in hospitals, community programs, supported living settings, and other healthcare environments.
Multiple population-based cohorts document that advances in healthcare, improved childhood survival, and the transition from institutional to community-based services have contributed to a substantial increase in life expectancy among individuals with intellectual and developmental disabilities (IDD). As this population ages, the demand for comprehensive, coordinated, and specialized support services continues to grow. Community living, inclusion, autonomy, dignity, and person-centered choice remain fundamental goals for people with IDD. At the same time, some individuals have highly complex medical, behavioral, psychiatric, functional, or support needs that require intensive and well-coordinated services. The need for greater clinical intensity should not, by itself, determine where a person lives; rather, it underscores the responsibility of health and support systems to build the expertise, staffing, and infrastructure necessary to meet those needs in the least restrictive and most person-centered setting possible. In Texas, the State Supported Living Centers (SSLCs) continue to serve individuals with significant and often complex needs. The experience described in this article is therefore not intended as an argument for institutional care, but as an account of clinical and quality-improvement practices developed within the SSLC system that may offer useful lessons for improving IDD healthcare across residential, community, outpatient, and hospital settings.
In 2012, after more than two decades in traditional medical practice, I was introduced to the SSLC system by two physician colleagues who were already serving in leadership positions within the Texas system. Entering the field of IDD healthcare without formal training in the specialized and often complex health needs of this population, I faced a challenging learning curve. Over time, however, I developed a profound appreciation for both the rewards and the clinical responsibilities associated with caring for individuals with IDD. Just as importantly, I came to recognize how frequently poor outcomes reflect gaps in systems of care rather than the individual’s disability itself.
As my experience grew, two critical needs became increasingly evident. First, there was a pressing need for earlier identification, prevention, and intervention for reversible health conditions that occur disproportionately among individuals with IDD—a recognition that fueled my interest in addressing conditions commonly referred to as the “Fatal Five Plus”: aspiration pneumonia, infections leading to sepsis, seizures, dehydration, constipation, and gastro-esophageal reflux disease (GERD). Second, there was a need to strengthen interdisciplinary collaboration through education and training focused on evidence-based, person-centered, quality-assured healthcare, as well as better communication and coordination among SSLC primary care providers (PCPs), community specialists, emergency physicians, hospitalists, hospital-based specialists, nursing teams, and other professionals. Contributing significantly to these gaps was the limited exposure to IDD healthcare within traditional medical school curricula and residency training programs. These are not challenges unique to institutional settings; they are recurring weaknesses throughout the broader healthcare system serving people with IDD.
Upon assuming the role of Medical Director at the Austin SSLC in 2018, I began advancing initiatives designed to address these clinical and systemic gaps. Meaningful and sustainable change required persistence, strategic planning, and ongoing commitment. The knowledge and experience gained through this leadership role ultimately informed a broader vision for statewide improvement, with the potential for lessons learned within the SSLC system to strengthen care beyond the facilities themselves.
In November 2022, during my first month as Medical Services Coordinator for Texas’ thirteen SSLCs, I envisioned a comprehensive statewide master plan built upon a “Four Pillars” framework. This strategic initiative was designed to address the two critical areas of improvement described above while creating a structure that could generate practical lessons for high-quality IDD healthcare across settings.
Transforming IDD Clinical Care
When I first transitioned into the world of IDD medical care, I had to completely reframe my clinical perspective. Traditional medical education often compartmentalizes care, but the complex health vulnerabilities of many individuals with IDD demand a unified, highly synchronized interdisciplinary approach. I came to understand that the central issue was not where a person lived, but whether the healthcare system around that person could recognize risk early, communicate effectively, coordinate across disciplines, and respond in a person-centered way. This realization inspired my effort to develop a four-pillar strategy and systematically implement it across the Texas SSLC system.
My Journey Implementing the Four Pillars Strategy in Texas
To transform healthcare delivery from a reactive model to a proactive, preventive system, I established a comprehensive framework built on four essential cornerstones: Good Communication, Strong Medical Education, a Solid Quality Assurance/Quality Improvement Process, and Targeted Strategies for Staff Retention and Recruitment. By systematically operationalizing these pillars across all thirteen state facilities, we sought to move beyond compliance and elevate the quality of daily clinical care. Importantly, these pillars are not unique to SSLCs; they represent foundational elements of good healthcare that can be adapted to community programs, outpatient practices, hospitals, supported living settings, and other systems serving people with IDD.
Pillar 1: Standardizing Clinical Communication
Effective communication is the backbone of safe, high-quality clinical care. Within any complex healthcare or residential support system, communication gaps can contribute to fragmented decision-making, delayed intervention, and preventable adverse outcomes. For this reason, the first pillar focused on standardizing communication processes across all facilities, with practices that may also be adaptable to community-based care.
The Quality Morning Medical Report
In December 2022, the Morning Medical Report template was substantially revised to include clinical information related to the Fatal Five Plus: Aspiration Pneumonia, Sepsis, Seizures, Dehydration, Constipation, and gastro-esophageal reflux disease. The revised report functions as a daily operational tool by consolidating key updates from the Medical director (who leads the meeting), the on-call primary care provider, the nursing leadership (daily nursing report), the infirmary nursing staff, the behavioral health specialists, the psychiatrists (report on updated psychiatry medications), the Dentist/dental services, the Hospital liaison Nurse (daily hospital transition report), the Infectious disease Nurse (daily antibiotic stewardship report), the Clinical pharmacist, the QIDP services representative, the Unit directors and the facility director. This centralized process allows unresolved clinical issues and recent hospital/infirmary admissions and discharges to be reviewed proactively by the interdisciplinary team each morning. This comprehensive interdisciplinary clinical meeting provides valuable information that informs both the daily Facility Unit Meetings and the subsequent daily Incident Management Review Team (IMRT) Meeting.
Statewide Coordination & Interdisciplinary Alignment
To maintain leadership alignment, medical department meetings were instituted at all thirteen facilities, led by each facility’s Medical Director, and held weekly or at least monthly. A statewide monthly Medical Directors meeting was also launched in January 2023 under my direction. During each facility’s Annual State Office Review Team (SRT) process, the state medical reviewer uses a standardized questionnaire that is used with the facility Medical Director to evaluate local resources, identify barriers, and support consistent statewide improvement.
Because effective communication between primary care providers and frontline nursing staff is essential to safe patient care, we developed an annual progressive training track to address historical communication barriers. Starting in January of 2023, this training was conducted at each center during the facility Annual State Office Review. The training conducted by me at all 13 facilities included:
2023: Built systemwide awareness of the importance of effective communication by reviewing an actual clinical encounter from center in which poor PCP-nurse communication contributed to an unfavorable clinical outcome.
2024: Training was conducted targeting specific communication gaps that directly affected clinical outcomes, with a strong focus on the Fatal Five Plus.
2025: Training was conducted by introducing evidence-based information and peer-reviewed clinical literature to examine root causes of communication gaps and identify practical remedial actions.
2026: Reinforced communication pathways across three frontline areas: executive leadership alignment, PCP-to-floor nurse interactions, and PCP-to-case management coordination. The training was followed by a standardized questionnaire for primary care providers, case managers, and floor nurses to identify practical strategies for strengthening PCP-nurse communication.
Pillar 2: Strengthening Medical Education
IDD-focused clinical education is essential because many physicians and other healthcare professionals receive limited formal training in IDD healthcare during medical school, residency, or standard professional education. The second pillar therefore focused on providing ongoing, accredited education tailored to the clinical complexity of the individuals served within the SSLC system while recognizing that the same knowledge is urgently needed by clinicians caring for people with IDD in community and hospital settings.
Through our Health and Specialty Care Services Lunchtime CME Program, I delivered one-hour educational sessions for providers in the state HHSC system on a wide range of clinical topics, including antibiotic stewardship, GERD, dementia, Monkeypox (mpox), and colonic volvulus.
Since initiating the monthly Medical Directors meetings, I have covered 36 distinct clinical topics for audiences that typically include the medical directors, primary care providers, medical compliance nurses, facility directors, and other staff. Building on this momentum, we launched a premium CME program in June 2026, bringing in specialized experts to present on clinical topics such as epilepsy, breast cancer, and topics targeting ethical issues such as challenges in clinical decision-making, patient-centered care, etc.
Pillar 3: Establishing a Strong QA/QI Process
The third pillar focused on strengthening QA/QI processes. Using the 80/20 Rule, or Pareto Principle, the strategy emphasized high-impact clinical processes and audit interventions most likely to influence meaningful patient outcomes. The Quality Status Review (QSR) audit tool, used across all thirteen facilities, was color-coded to highlight outcome indicators with the greatest impact on patient outcomes. Beginning in 2023, targeted training sessions were incorporated into each facility's Annual State Office Review process to ensure that Medical Directors, primary care providers, medical compliance nurses, and quality assurance/quality improvement (QA/QI) staff understood how the QSR tool could be used to support and enhance the quality of clinical care.
State office reviewers now audit selected high-impact clinical indicators from the QSR tool every six months to help measure and reduce inter-rater variability throughout all 13 facilities.
A major milestone occurred in October 2024, when we introduced an updated QSR tool focused on Outcome 8: the Interval Medical Review (IMR). The updated IMR was designed not as a documentation checklist, but as a dynamic clinical process tool. Each quarter, the primary care providers review the individual’s interval history, update active problem lists, revise care plans based on recent clinical developments, and adjust goals and interventions for medium- and high-risk areas to keep the interdisciplinary team aligned.
Targeted Initiative: Confronting Aspiration Pneumonia
Because aspiration pneumonia has historically accounted for 50% to 60% of resident deaths within the SSLC system, we launched the Pneumonia Review Committee across all thirteen facilities in June 2025. Led by facility Medical Directors and coordinated through the Physical Nutritional Management Team (PNMT), the committee uses a structured, three-step, patient-centered review process:
Step 1: Review the active problem list to identify all diagnoses related to aspiration risk.
Step 2: Confirm that each identified aspiration risk diagnosis is being optimally managed with input from the appropriate subject matter experts which include physician consultants who are involved with the individual’s care.
Step 3: Ask each relevant discipline to review their discipline specific standardized aspiration checklist and identify latent risk areas before they compromise patient health.
Targeted Initiative: Specialized Neurology and Epilepsy and Dementia Management
To further strengthen the QA/QI framework, we established a dedicated State Office Neurologist/Epileptologist position in January 2026. This role has helped optimize complex epilepsy medication regimens, reduce drug burden and polypharmacy, develop educational materials to help staff identify seizure types, and provide continuing education/CME for primary care providers on topics related to Neurology. Further, we are developing a “Zero Seizure Initiative” by incorporating a seizure identification algorithm into our newly purchased electronic medical record (EMR), with a view to be enabling us to monitor a resident’s seizure frequency and intensity and thereby the averaged seizure load, which can be monitored day-to-day, week-to-week, month-to-month and year-to-year, in relation to various physical, physiological, emotional and pathological stressors and other interventions such as the addition or removal of medication(S) and changes in dosage. The position also supports statewide monitoring of cognitive decline by promoting the use of standardized national screening tools such as the one developed by the National Task Group (NTG) on IDD practices across aging populations to help care givers and staff identify early cognitive and functional changes in adults with IDD. The NTG-Early detection screen for dementia (NTG-EDSD tool) tool, as the name implies, is only a screening and not a diagnostic one. The state office Neurologist is a certified trainer of the NTG-EDSD tool.
Pillar 4: Supporting Staff Retention and Recruitment
The fourth pillar recognizes that sustainable clinical improvement depends on the stability, well-being, competence, and engagement of the professionals responsible for delivering care. Under this pillar, the focus has been on building organized and highly structured clinical environments across facilities. Greater operational clarity and streamlined workflows can reduce confusion, decrease occupational stress, and support provider retention. The broader lesson is equally applicable to community systems, where workforce instability and turnover can directly threaten continuity, safety, and person-centered care.
Concurrently, we initiated outreach efforts with local community hospitals, medical schools, and physician residency programs to increase awareness of healthcare opportunities involving individuals with intellectual and developmental disabilities (IDD).
Although these efforts have been challenging, our long-term vision is to introduce residents and early-career physicians to the clinical complexity, unique rewards, and professional significance of IDD healthcare. The goal should extend beyond recruitment into the state-supported system itself: clinicians who gain experience with complex IDD healthcare can carry that knowledge into community practices, hospitals, academic programs, group homes, supported living services, and other settings throughout Texas. In this way, the SSLC system can function not only as a site of care, but also as a source of clinical expertise and workforce development for the broader IDD healthcare community.
Future Directions
The clinical transformation described in this article remains ongoing. Four statewide priorities are currently guiding the next phase of work, with an increasing emphasis on how lessons developed within the SSLC system can strengthen healthcare for people with IDD across settings:
Standardizing cognitive screening
Although the NTG-EDSD tool is already being used in some of our facilities, we are working toward its universal implementation across all thirteen facilities to strengthen the assessment of cognitive decline and provide clinicians with a more robust foundation for clinical and ethical decision-making in aging individuals with intellectual and developmental disabilities (IDD).
Strengthening hospital partnerships
We are encouraging all thirteen facilities to establish annual leadership meetings with their local community hospitals. By strengthening communication and collaboration among SSLC primary care providers, emergency department physicians, hospitalists, and hospital-based specialists, we can improve information sharing and leverage our standardized Interval Medical Reviews to facilitate smoother care transitions and enhance continuity of care.
Expanding national academic collaboration
I am working to initiate collaborations with prominent national organizations, including the American Academy of Developmental Medicine and Dentistry (AADMD), the National Task Group on Intellectual Disabilities and Dementia Practices, Disability inspired medical education (DIME) project and National Inclusion Curriculum for Health Education (NICHE-Med). These and other partnerships will help us gain guidance from national and international experts while also sharing the lessons we have learned through years of work in Texas.
Translating Specialized Expertise into Community Capacity
A central future goal should be to identify which clinical processes and expertise developed within the Texas SSLC system can be adapted to strengthen community-based care. This may include consultation and education for community clinicians and direct support professionals, approaches to aspiration prevention and seizure recognition, dementia screening support, improved transitions between residential settings and hospitals, and partnerships with training programs. Texas SSLCs are also continuing efforts to strengthen person-centered transition planning, community provider partnerships, pre- and post-move supports, and awareness of community living options. People with complex IDD should not have to live in a specialized facility in order to benefit from specialized clinical knowledge; wherever possible, that expertise should travel with the person and support safe, successful community living.
By strengthening communication, medical education, quality improvement, workforce development, and the transfer of specialized knowledge beyond facility walls, the Texas SSLC system can contribute to the broader national movement toward high-quality, community-based care for people with IDD. The expertise and dedication of SSLC clinicians and other professionals remain essential for individuals currently served in these settings, while ongoing transition efforts can help extend that knowledge into the community. The larger goal is to ensure that people with IDD can receive safe, competent, coordinated, person-centered healthcare wherever they live, recognizing clinical excellence, dignity, autonomy, inclusion, and community participation as complementary rather than competing goals.
Acknowledgements
I would like to extend special thanks to the two State Office Quality Assurance physicians, facility medical directors, primary care providers, medical compliance RNs, and other support staff who played a critical role in implementing these changes.
Finally, I would like to express my sincere gratitude to the State Office leadership of Behavioral Health, Disability and Aging Services, Health and Specialty Care Services, Texas Health and Human Services, for their unwavering encouragement, guidance, and support throughout the years. Their commitment to improving the lives of individuals with intellectual and developmental disabilities has been instrumental in advancing these initiatives and fostering continued quality improvement across the SSLC system.
About the Author
Dr. Ashton Wickramasinghe is a Board-certified internal medicine physician with extensive experience in outpatient care, complex patient management, and healthcare leadership within state-supported systems. Expertise includes clinical operations, interdisciplinary coordination, regulatory compliance, and quality improvement initiatives. Proven record of leading medical departments and advancing key regulatory and operational goals.