Category: General/Lifestyle

Over the next several months we will be taking an in-depth look at each of the 22 items on the HRST. The first major category is Functional Status, which deals with those activities each of us performs (and often takes for granted) on a daily basis. This broader category contains five separate items: Eating, Ambulation, Transfer, Toileting, and Clinical Issues Affecting Daily Life. We will cover each of those individually in the coming issues, but I feel it is important to give some background on the subject before we begin.

There are two very good reasons that issues with functional status appear on an instrument that concerns itself with risk identification and management. First, in their most extreme forms, these issues indicate extreme needs for support to prevent severe injury or even loss of life. Individuals requiring the most assistance with eating mobility also have demonstrably higher death rates. Incontinence and the need for catheterization carry significant risks for infection, skin breakdown and disorders of the urinary tract and bowel. Lastly, the degree to which a person’s health or behavioral issues impact their life has a direct impact upon their ability to participate in expected daily activities such as school, work or social activities.

One of the biggest disservices we do for individuals with special needs is to assume that health and wellness issues cannot be improved…

Secondly, loss of functional skills is often the first noticeable sign of declining health status. Examples of patterns which should raise red flags include:

• Going from eating independently to requiring direct assistance, an altered texture diet or a feeding tube.
• Going from being able to walk and move from one position to another to needing supervisory support, a wheelchair, mechanical seating support or lift equipment.
• Progressive loss of toileting skills involving hygiene, continence or requiring assistance to empty the bladder.
• Increasing numbers of days where usual activities are impacted by the need to address clinical issues.

One of the biggest disservices we do for individuals with special needs is to assume that health and wellness issues cannot be improved or, even worse, that progressive loss of skills over time is “normal” Deterioration, in spite of the most skilled intervention, may well be inevitable. It should never be regarded as normal. It is always a sign that something is going on. In many cases loss of skill is an early opportunity to begin looking for and correcting root cause. In those with long-standing functional deficits there are often opportunities to provide interventions that support the person more successfully around their issues or improve skills to lessen the risk.

Next month’s article will discuss issues with Eating, how they can negatively impact a person’s health and quality of life and how even serious issues can be addressed in ways that reduce the potential for unwanted health consequence. 

Improving Quality of Life for those with Intellectual and Developmental Disabilities

Primary Functions of the HRST and SIS

Since the last newsletter we received a lot of interest regarding the use of the HRST and the SIS. We have included some information below about how these two tools work together.

HRST

The HRST is a reliable web-based rating instrument developed to screen for health risks associated with a wide variety of disabilities, including developmental disabilities, physical disabilities, disabilities associated with aging, and many other conditions, which specifically affect systems of the body and the person’s ability to engage in functional activities. It is designed to primarily detect destabilization EARLY and PREVENT preventable illness and even death. It has the ability to detect health risk that can lead to illness and death. It accomplishes this by having the interviewer rate 22 rating items that span over 5 categories: Functional Status, Behavior, Physiological, Safety, and Frequency of Services. Once scoring is complete the HRST produces an overall Health Care Level (HCL) that corresponds to the person’s risk level. The HRST also produces a set of Considerations that assist the team in identifying other professional services and training that may be needed for the person based off the scoring of the 22 items. The HRST has been shown to reduce morbidity, reduce costs related to service delivery, lead to more accurate parallel of supports/services to needs of the person, better staffing alignment based off of identified needs, greater identification of at-risk individuals, and improved quality of life for the person due to better overall health.

SIS

Developed, tested, and normed by the American Association on Intellectual and Developmental Disabilities (AAIDD), the Supports Intensity Scale is a unique supports identifying tool for ages 16 and older. It primarily seeks to assess and measure the support needs for persons with intellectual and developmental disabilities to engage in a given activity at the same level of involvement as anyone without a disability of relative age in his or her community (also defined as, Success). The SIS covers a number of life activities some of which have historically been unassociated with, or participated in, by people with disabilities. The interviewer is tasked with exploring a number of activities in the sections of Home Living, Community Living, Lifelong Learning, Employment, Health and Safety, Social and Protection/Advocacy. The interviewer then works with the team to identify what Type of Support, Frequencyof Support, and Daily Support Time would be needed to ensure success. The majority of the tool is scored in this manner. The SIS helps identify the supports needed for maximum contribution in everyday tasks. It also addresses stereotypical norms by refocusing, not on the deficits of the person, but rather on accurate supports to engage in life like others do.

Using HRST and SIS

Due to the intended nature and purpose of the HRST and the SIS, users may find that these two tools work well together in a number of ways. Each tool takes a different approach when evaluating the person.

Both tools can be used to:

• Develop Individualized Support Plans.
• Allocate fiscal resources based of identified risk and support level.
• Allocate staff and personnel.
• Qualify for advanced funding and supports.
• Identify quality of life dynamics.
• Trend data.
• Assist in continuity of care.
• Aid in transition efforts from higher levels of care.

The first person I met who had severe cerebral palsy also had a Ph.D. A friend and colleague of my mother’s, she was the Director of Special Programs for individuals with complex sensorimotor issues at Glenwood State Hospital School in Southwest Iowa. Visits to her home, where she lived with the assistance of a personal aide, were pleasant interludes where the adults conversed over coffee and my brother and I played in the shady backyard. They were an integral part of my definition of a normal childhood.

Those who became involved in the field by the mid 1960’s (yes, there are still several out there) did so at an extraordinary time in history as it relates to people with disabilities. It was the tail-end of the time when families automatically handed “hopelessly crippled” over children at birth, many to see them only a few times a year, if ever. It was a time when individuals in custodial settings, including prisons, were literally regarded by the system as legally dead in terms of their personal rights. In other words, they had none. Over the past fifty or so years we have been treated to a front-row seat at the growth spurt in our understanding and treatment of people with specialized needs.

In 1965 a person with Down Syndrome could expect to live only until their mid-twenties, 75% of individuals with cerebral palsy were also diagnosed as having an intellectual disability, as opposed to 25% today. If you had hit the average citizen with the term “mainstreaming,” they would probably have thought you were referring to an innovation in the field of civil engineering. In 2014 people across a wide range of disabilities can expect to live a life span equal to or approaching that of the population at large. They can expect to be college graduates, business owners and valuable members of their extended communities.

HRS Inc’s stated goal over the past several years has always been to prevent those negative health events that are preventable through identification and appropriate intervention at the earliest possible point.

Technology and medicine have made great strides in the past fifty years. Access to education and employment are greatly improved and more people are remaining with families, guardians or living independently with supports. Wonderful things, all of them, but we face continued and growing concerns over community acceptance and access to needed services. It therefore begs the question, how do we keep what we’ve gained and continue to progress? The answer to these questions will never be simple but they can be distilled down to some very basic elements: Reduce the need for intervention when and wherever possible as well as support and promote things that are already working.

Our friend from the early days in Southwest Iowa came to share our common path by design, not by accident. She had a mother who loved and believed in her at a time when her family, her community and virtually every health care professional probably considered her, well, let’s be kind and say…unique. She made every possible resource available to her daughter against great odds and she, her daughter and the special needs community were rewarded by her vision and perseverance. In many ways we are and will continue to face increasing challenges today and into the future. Funds are dwindling and there is still much ground to be gained in enjoying access to the wide world. If it could be done in the 50’s and 60’s it can certainly be done now. How we choose to do so will continue to define the path of this community.

Building a Better Future

The first person I met who had severe cerebral palsy also had a Ph.D. A friend and colleague of my mother’s, she was the Director of Special Programs for individuals with complex sensorimotor issues at Glenwood State Hospital School in Southwest Iowa. Visits to her home, where she lived with the assistance of a personal aide, were pleasant interludes where the adults conversed over coffee and my brother and I played in the shady backyard. They were an integral part of my definition of a normal childhood.

Those who became involved in the field by the mid 1960’s (yes, there are still several out there) did so at an extraordinary time in history as it relates to people with disabilities. It was the tail-end of the time when families automatically handed “hopelessly crippled” over children at birth, many to see them only a few times a year, if ever. It was a time when individuals in custodial settings, including prisons, were literally regarded by the system as legally dead in terms of their personal rights. In other words, they had none. Over the past fifty or so years we have been treated to a front-row seat at the growth spurt in our understanding and treatment of people with specialized needs.

In 1965 a person with Down Syndrome could expect to live only until their mid-twenties, 75% of individuals with cerebral palsy were also diagnosed as having an intellectual disability, as opposed to 25% today. If you had hit the average citizen with the term “mainstreaming,” they would probably have thought you were referring to an innovation in the field of civil engineering. In 2014 people across a wide range of disabilities can expect to live a life span equal to or approaching that of the population at large. They can expect to be college graduates, business owners and valuable members of their extended communities.

HRS Inc’s stated goal over the past several years has always been to prevent those negative health events that are preventable through identification and appropriate intervention at the earliest possible point.

Technology and medicine have made great strides in the past fifty years. Access to education and employment are greatly improved and more people are remaining with families, guardians or living independently with supports. Wonderful things, all of them, but we face continued and growing concerns over community acceptance and access to needed services. It therefore begs the question, how do we keep what we’ve gained and continue to progress? The answer to these questions will never be simple but they can be distilled down to some very basic elements: Reduce the need for intervention when and wherever possible as well as support and promote things that are already working.

Our friend from the early days in Southwest Iowa came to share our common path by design, not by accident. She had a mother who loved and believed in her at a time when her family, her community and virtually every health care professional probably considered her, well, let’s be kind and say…unique. She made every possible resource available to her daughter against great odds and she, her daughter and the special needs community were rewarded by her vision and perseverance. In many ways we are and will continue to face increasing challenges today and into the future. Funds are dwindling and there is still much ground to be gained in enjoying access to the wide world. If it could be done in the 50’s and 60’s it can certainly be done now. How we choose to do so will continue to define the path of this community.

Building a Better Future

The next several articles in future newsletters will deal with each of the areas of the HRST and discuss how they can be used to identify both areas of need and non-need. “Normal” is such a loaded word, but every person in the world is afflicted with it invarying amounts and in one form or another. HRS Inc’s stated goal over the past several years has always been to prevent those negative health events that are preventable through identification and appropriate intervention at the earliest possible point. The unspoken opposite side of that is that we don’t hassle people when they don’t need it. Unnecessary interventions can be an expensive nuisance. They often prevent the public at large from seeing that they share more similarities than differences with individuals with special needs. They can also prevent gains in an individual’s personal growth and development. Nobody who works in the supportive care field and most compassionate humans do not want to see anyone go without the things they genuinely need. With good advocacy and the proper supports it doesn’t have to happen.

The first person I met who had severe cerebral palsy also had a Ph.D. A friend and colleague of my mother’s, she was the Director of Special Programs for individuals with complex sensorimotor issues at Glenwood State Hospital School in Southwest Iowa. Visits to her home, where she lived with the assistance of a personal aide, were pleasant interludes where the adults conversed over coffee and my brother and I played in the shady backyard. They were an integral part of my definition of a normal childhood.

Those who became involved in the field by the mid 1960’s (yes, there are still several out there) did so at an extraordinary time in history as it relates to people with disabilities. It was the tail-end of the time when families automatically handed “hopelessly crippled” over children at birth, many to see them only a few times a year, if ever. It was a time when individuals in custodial settings, including prisons, were literally regarded by the system as legally dead in terms of their personal rights. In other words, they had none. Over the past fifty or so years we have been treated to a front-row seat at the growth spurt in our understanding and treatment of people with specialized needs.

In 1965 a person with Down Syndrome could expect to live only until their mid-twenties, 75% of individuals with cerebral palsy were also diagnosed as having an intellectual disability, as opposed to 25% today. If you had hit the average citizen with the term “mainstreaming,” they would probably have thought you were referring to an innovation in the field of civil engineering. In 2014 people across a wide range of disabilities can expect to live a life span equal to or approaching that of the population at large. They can expect to be college graduates, business owners and valuable members of their extended communities.

HRS Inc’s stated goal over the past several years has always been to prevent those negative health events that are preventable through identification and appropriate intervention at the earliest possible point.

Technology and medicine have made great strides in the past fifty years. Access to education and employment are greatly improved and more people are remaining with families, guardians or living independently with supports. Wonderful things, all of them, but we face continued and growing concerns over community acceptance and access to needed services. It therefore begs the question, how do we keep what we’ve gained and continue to progress? The answer to these questions will never be simple but they can be distilled down to some very basic elements: Reduce the need for intervention when and wherever possible as well as support and promote things that are already working.

Our friend from the early days in Southwest Iowa came to share our common path by design, not by accident. She had a mother who loved and believed in her at a time when her family, her community and virtually every health care professional probably considered her, well, let’s be kind and say…unique. She made every possible resource available to her daughter against great odds and she, her daughter and the special needs community were rewarded by her vision and perseverance. In many ways we are and will continue to face increasing challenges today and into the future. Funds are dwindling and there is still much ground to be gained in enjoying access to the wide world. If it could be done in the 50’s and 60’s it can certainly be done now. How we choose to do so will continue to define the path of this community.

Building a Better Future

The next several articles in future newsletters will deal with each of the areas of the HRST and discuss how they can be used to identify both areas of need and non-need. “Normal” is such a loaded word, but every person in the world is afflicted with it invarying amounts and in one form or another. HRS Inc’s stated goal over the past several years has always been to prevent those negative health events that are preventable through identification and appropriate intervention at the earliest possible point. The unspoken opposite side of that is that we don’t hassle people when they don’t need it. Unnecessary interventions can be an expensive nuisance. They often prevent the public at large from seeing that they share more similarities than differences with individuals with special needs. They can also prevent gains in an individual’s personal growth and development. Nobody who works in the supportive care field and most compassionate humans do not want to see anyone go without the things they genuinely need. With good advocacy and the proper supports it doesn’t have to happen.

The first person I met who had severe cerebral palsy also had a Ph.D. A friend and colleague of my mother’s, she was the Director of Special Programs for individuals with complex sensorimotor issues at Glenwood State Hospital School in Southwest Iowa. Visits to her home, where she lived with the assistance of a personal aide, were pleasant interludes where the adults conversed over coffee and my brother and I played in the shady backyard. They were an integral part of my definition of a normal childhood.

Those who became involved in the field by the mid 1960’s (yes, there are still several out there) did so at an extraordinary time in history as it relates to people with disabilities. It was the tail-end of the time when families automatically handed “hopelessly crippled” over children at birth, many to see them only a few times a year, if ever. It was a time when individuals in custodial settings, including prisons, were literally regarded by the system as legally dead in terms of their personal rights. In other words, they had none. Over the past fifty or so years we have been treated to a front-row seat at the growth spurt in our understanding and treatment of people with specialized needs.

In 1965 a person with Down Syndrome could expect to live only until their mid-twenties, 75% of individuals with cerebral palsy were also diagnosed as having an intellectual disability, as opposed to 25% today. If you had hit the average citizen with the term “mainstreaming,” they would probably have thought you were referring to an innovation in the field of civil engineering. In 2014 people across a wide range of disabilities can expect to live a life span equal to or approaching that of the population at large. They can expect to be college graduates, business owners and valuable members of their extended communities.

HRS Inc’s stated goal over the past several years has always been to prevent those negative health events that are preventable through identification and appropriate intervention at the earliest possible point.

Technology and medicine have made great strides in the past fifty years. Access to education and employment are greatly improved and more people are remaining with families, guardians or living independently with supports. Wonderful things, all of them, but we face continued and growing concerns over community acceptance and access to needed services. It therefore begs the question, how do we keep what we’ve gained and continue to progress? The answer to these questions will never be simple but they can be distilled down to some very basic elements: Reduce the need for intervention when and wherever possible as well as support and promote things that are already working.

Our friend from the early days in Southwest Iowa came to share our common path by design, not by accident. She had a mother who loved and believed in her at a time when her family, her community and virtually every health care professional probably considered her, well, let’s be kind and say…unique. She made every possible resource available to her daughter against great odds and she, her daughter and the special needs community were rewarded by her vision and perseverance. In many ways we are and will continue to face increasing challenges today and into the future. Funds are dwindling and there is still much ground to be gained in enjoying access to the wide world. If it could be done in the 50’s and 60’s it can certainly be done now. How we choose to do so will continue to define the path of this community.

Building a Better Future

The next several articles in future newsletters will deal with each of the areas of the HRST and discuss how they can be used to identify both areas of need and non-need. “Normal” is such a loaded word, but every person in the world is afflicted with it invarying amounts and in one form or another. HRS Inc’s stated goal over the past several years has always been to prevent those negative health events that are preventable through identification and appropriate intervention at the earliest possible point. The unspoken opposite side of that is that we don’t hassle people when they don’t need it. Unnecessary interventions can be an expensive nuisance. They often prevent the public at large from seeing that they share more similarities than differences with individuals with special needs. They can also prevent gains in an individual’s personal growth and development. Nobody who works in the supportive care field and most compassionate humans do not want to see anyone go without the things they genuinely need. With good advocacy and the proper supports it doesn’t have to happen.

The first person I met who had severe cerebral palsy also had a Ph.D. A friend and colleague of my mother’s, she was the Director of Special Programs for individuals with complex sensorimotor issues at Glenwood State Hospital School in Southwest Iowa. Visits to her home, where she lived with the assistance of a personal aide, were pleasant interludes where the adults conversed over coffee and my brother and I played in the shady backyard. They were an integral part of my definition of a normal childhood.

Those who became involved in the field by the mid 1960’s (yes, there are still several out there) did so at an extraordinary time in history as it relates to people with disabilities. It was the tail-end of the time when families automatically handed “hopelessly crippled” over children at birth, many to see them only a few times a year, if ever. It was a time when individuals in custodial settings, including prisons, were literally regarded by the system as legally dead in terms of their personal rights. In other words, they had none. Over the past fifty or so years we have been treated to a front-row seat at the growth spurt in our understanding and treatment of people with specialized needs.

In 1965 a person with Down Syndrome could expect to live only until their mid-twenties, 75% of individuals with cerebral palsy were also diagnosed as having an intellectual disability, as opposed to 25% today. If you had hit the average citizen with the term “mainstreaming,” they would probably have thought you were referring to an innovation in the field of civil engineering. In 2014 people across a wide range of disabilities can expect to live a life span equal to or approaching that of the population at large. They can expect to be college graduates, business owners and valuable members of their extended communities.

HRS Inc’s stated goal over the past several years has always been to prevent those negative health events that are preventable through identification and appropriate intervention at the earliest possible point.

Technology and medicine have made great strides in the past fifty years. Access to education and employment are greatly improved and more people are remaining with families, guardians or living independently with supports. Wonderful things, all of them, but we face continued and growing concerns over community acceptance and access to needed services. It therefore begs the question, how do we keep what we’ve gained and continue to progress? The answer to these questions will never be simple but they can be distilled down to some very basic elements: Reduce the need for intervention when and wherever possible as well as support and promote things that are already working.

Our friend from the early days in Southwest Iowa came to share our common path by design, not by accident. She had a mother who loved and believed in her at a time when her family, her community and virtually every health care professional probably considered her, well, let’s be kind and say…unique. She made every possible resource available to her daughter against great odds and she, her daughter and the special needs community were rewarded by her vision and perseverance. In many ways we are and will continue to face increasing challenges today and into the future. Funds are dwindling and there is still much ground to be gained in enjoying access to the wide world. If it could be done in the 50’s and 60’s it can certainly be done now. How we choose to do so will continue to define the path of this community.

Building a Better Future

The next several articles in future newsletters will deal with each of the areas of the HRST and discuss how they can be used to identify both areas of need and non-need. “Normal” is such a loaded word, but every person in the world is afflicted with it invarying amounts and in one form or another. HRS Inc’s stated goal over the past several years has always been to prevent those negative health events that are preventable through identification and appropriate intervention at the earliest possible point. The unspoken opposite side of that is that we don’t hassle people when they don’t need it. Unnecessary interventions can be an expensive nuisance. They often prevent the public at large from seeing that they share more similarities than differences with individuals with special needs. They can also prevent gains in an individual’s personal growth and development. Nobody who works in the supportive care field and most compassionate humans do not want to see anyone go without the things they genuinely need. With good advocacy and the proper supports it doesn’t have to happen.

The next several articles in future newsletters will deal with each of the areas of the HRST and discuss how they can be used to identify both areas of need and non-need. “Normal” is such a loaded word, but every person in the world is afflicted with it invarying amounts and in one form or another. HRS Inc’s stated goal over the past several years has always been to prevent those negative health events that are preventable through identification and appropriate intervention at the earliest possible point. The unspoken opposite side of that is that we don’t hassle people when they don’t need it. Unnecessary interventions can be an expensive nuisance. They often prevent the public at large from seeing that they share more similarities than differences with individuals with special needs. They can also prevent gains in an individual’s personal growth and development. Nobody who works in the supportive care field and most compassionate humans do not want to see anyone go without the things they genuinely need. With good advocacy and the proper supports it doesn’t have to happen.

Recognizing the Enemy is Half the Battle!

In last month’s newsletter we addressed The Fatal Five; the top five killers of people in both in both institutional and community settings. Over the next several months we would like to discuss each of them individually. This month we will be discussing GERD and how to recognize it in its many forms. When left untreated, not only is reflux extremely uncomfortable but it can lead to death from frank aspiration, GI bleed or esophageal cancer.

Gastroesophageal reflux disease or GERD is the reverse flow of stomach contents into the esophagus. Once outside the protected environment of the stomach, stomach acid can irritate and harm the esophagus, be inhaled or aspirated into the lungs, or damage the gums and teeth.

GERD is often nature’s way of telling us that our diet needs some attention. Foods that contain acid (tomatoes, citrus) excessive fats, coffee, alcohol, spicy foods, chocolate and mint may cause or worsen reflux. Carrying excessive weight, particularly around the abdomen, can exacerbate the symptoms of reflux, both due to lack of tone of the abdominal muscles and the mechanical pressure of the excess mass exerting upward pressure on the stomach and its contents.

Train those who work and live with vulnerable individuals to recognize and report the signs and symptoms of gastrointestinal disorders at the earliest possible time.

Individuals who have chronic health issues have an increased vulnerability to GERD. Other factors that can contribute to the development of reflux include significant physical disability (especially those that alter the anatomy of the GI tract), hiatal hernia, emotional and behavioral issues, tube feeding diets and, above all, medications (anticholinergics, muscle-relaxers, NSAIDS and MANY others.) Fortunately there are several easily recognizable factors that can indicate that a person has or is likely to develop reflux.

Common signs of reflux are burning pain in the upper abdominal or chest areas, regurgitation of stomach contents, meal refusal, belching and/or flatulence. Less commonly seen are behavioral signs such as hand-mouthing and PICA which, when present, have a 30% correlation with silent reflux. Other symptoms of silent reflux are unexplained weight loss, low serum albumin and progressive anemia.

Medications have been the most commonly used first line of defense against GERD. Proton pump inhibitors such as Prilosec (omeprazole) and Histamine-2 antagonists like Zantac (ranitidine) are frequently used. Problems with these medications include malabsorption of vitamin B-12 and protein. Fractures associated with impaired calcium absorption are also requently seen with long-term use.

Other steps that can be taken to combat reflux include:

• Maintain a proper body weight for height.
• Consume a well-balanced diet in reasonable portions three or more hours prior to bedtime.
• Avoid foods that are known to aggravate heartburn, keeping in mind that everyone benefits from the occasional indiscretion, especially those that are covered in chocolate.
• Identify medications that are associated with GI distress and discuss symptoms with the prescribing physician so that these are used only when absolutely necessary.
• Identify and use positions that promote emptying of the stomach.
• Promote the swallowing of saliva, which neutralizes acidic stomach contents by having individuals who drool evaluated and treated by a speech pathologist.
• Train those who work and live with vulnerable individuals to recognize and report the signs and symptoms of gastrointestinal disorders at the earliest possible time.

Gastrointestinal Rating Information for HRST Users

“Has this person shown signs or symptoms of GI problems, including behavioral signs, within the past year OR had a gastrointestinal bleed at ANY time in their life?”

This is the opening rating question for Item K. Gastrointestinal on the HRST. Any and all conditions affecting the GI tract are rated in this section, but please be aware that we do not wait for the physician to grant a diagnosis in order to score this item. Gastrointestinal issues are some of the most pervasive and under-diagnosed health problems in the world. They may only become evident when the person has experienced some kind of a crisis such as a gastrointestinal bleed or an aspiration event.

Important things to look for in the individuals you serve are food aversions or avoidance, excessive belching, heartburn, rumination, unexplained vomiting, appearance of ingested food, including feeding tube formula, in the back of the throat, coughing within three hours of meals or at night, hand-mouthing or PICA behaviors and unexplained or escalating behavioral issues. Above all, INQUIRE ABOUT THE USE OF OVER-THE-COUNTER MEDICATIONS FOR HEARTBURN, NAUSEA OR OTHER GI ISSUES!

If any of the above conditions or any other signs of possible GI issues have been observed in the past twelve months, answer YES to the first rating question on Rating Item K.

Gastrointestinal issues, once detected, are often easily treated. In almost all cases the earlier an issue is caught the fewer long term consequences will result, resulting in a happier person with a much better outlook in terms of their overall health and quality of life.

Welcome to 2017 and to all new HRST newsletter subscribers! It seems just like yesterday that we were all worried that Y2K was going to crash all computer systems and the world would come to a screeching halt! Now 17 years later, computers are smaller, faster and have more capabilities and our world is still intact. Some things haven’t changed in 17 years, though. The tradition of making New Year’s Resolutions seems to persist although it has been proven time and time again that few people keep those well-meaning pledges. In this article, though, I would like to give you 3 New Year’s Resolutions that you can keep.

Whenever we have the opportunity to improve the quality of life or health for an individual, we should advocate.

1. Always advocate for the individuals that you serve.Whenever we have the opportunity to improve the quality of life or health for an individual, we should advocate. Advocating for someone is just speaking the words that they would say on their own behalf if they had the capabilities. Maybe you know someone who is very physically disabled but is fascinated with bowling. Can you find a way to take that person to bowl? Maybe they just sit on the lane while you throw the ball for them. Maybe just sitting in a bowling alley among all the noise and activity is enough. The important thing is to MAKE IT HAPPEN!
2. Document and report any and all changes in the individuals you serveIt doesn’t matter if you are the person closest to the individual or the person farthest away from the individual, if you see something, say something! That has become somewhat of a trite phrase, but if you notice something different, no matter how small, PLEASE report that change. You may be saving someone’s life. I served an individual who was a huge coffee drinker and loved his snacks. His direct support professional called me one Sunday evening and said he did not want any coffee or his snack and wanted to go to bed. We took him to ER and he was diagnosed with pneumonia. No fever, no cough, no other symptoms at all- he just didn’t want his coffee and snacks. Had the staff not noticed this small change and felt it warranted notification of someone, he might not have received treatment at the early stage of his disease.
3. Make sure to let your work partners know they are valued.All of us are partners in providing services to individuals and, really, none of us are more important than the other. None of us can do this difficult job alone. I once worked for a company where everyone employed by the company was called a “partner”, not an “employee.” We need the direct support professionals to provide direct care and improve individuals’ skills by implementation of programs. We need the QDDP to write the programs and keep the agency in compliance with regulatory standards. We need the nurse to educate on health and wellness and identify actual or potential health issues with individuals. We need the executive director to run the business so everyone is paid for the services they provide and to provide for adequate housing, meals and other needs for individuals served. Notice the small things that someone does. Appreciation doesn’t have to include a big bonus or a raise; a simple “Thank You” goes a very long way.So, after that expensive gym membership goes unused, the size 6 dress still doesn’t fit and the elliptical machine becomes a clothes hanger, please keep in mind these three resolutions above.

They will truly make a difference and require no cash outlay or additional time that no one has enough of already. Little things make all the difference in the world!

Bowel obstruction has a wide variety of causes and often results in the need for hospitalization or surgery. It is the most common cause of preventable death in individuals with ID/DD in community settings. This article will help identify some of the issues that lead to constipation and bowel obstruction in this population and give information about prevention and early response.

Bowel obstruction occurs when the large or small bowel becomes partially or completely blocked. While there are many causes, the primary issue in people with ID/DD is chronic constipation. The controllable factors that most commonly contribute to this are:

• Diet,
• Medications,
• Lack of movement.

Dietary contributors to constipation include lack of sufficient dietary fiber and/or inadequate fluid intake. There are also several foods that can either inhibit or promote normal bowel function. Most nutritionists recommend a daily fiber intake of 25 to 40 grams, preferably from regular foods rather than from psyllium or other artificial sources. Good ources of dietary fiber are fruits, vegetables and nuts WITH skins, whole grains products and many kinds of beans and legumes. Meat, eggs and many processed foods do not contain fiber. Fiber content is part of the information displayed on food nutrition labels.

Any person with a history of bowel obstruction needs particular care and surveillance as the bowel now has scar tissue that makes a repeat obstruction highly likely.

Obtaining adequate amounts of fluid is also crucial in assisting with prevention of constipation. Inadequate fluid intake can result in hard, compact stools that are difficult to pass. Water is of course the best beverage, though many people do not particularly care for it. Milk and juice are also good sources but may be unacceptable due to intolerance or high sugar content. Coffee, tea and soda are less desirable because they are high in caffeine and acid, which are dehydrating to the body. Alcoholic beverages act as a diuretic. Recommended fluid intake varies widely depending upon the individual’s gender, size, age and overall health. Several sources recommend approximately 2.5 liters per day for women and 3 liters per day for men

Almost 2/3 of all drugs, whether prescription or over the counter, have anticholinergic properties either as an intended effect or a side effect. This means that they dry out secretions and interfere with the contraction of smooth muscle, including the stripping action of the GI tract. Given that persons with disabilities and the elderly are the most over-medicated people in our nation, it is no surprise that they suffer from constipation at such an alarming rate. Use of medications to relieve constipation causes the gut to lose its enthusiasm for doing its job and, in the long run, make the problem worse rather than better. An important step in preventing constipation and bowel obstruction is to eliminate all drugs that are not strictly necessary. The healthiest persons with disabilities are on the fewest medications.

Another issue is the lack of active movement, particularly if we are aging or have physical disabilities. The bowel needs the stimulus of movement and the assistance of gravity to increase its enthusiasm for doing its job. Positions that stimulate the abdomen and increase active movement are also helpful to stimulate the gut. A 30 minute walk every day may also bebeneficial for persons with the motor skills to do so.

Any person with a history of bowel obstruction needs particular care and surveillance as the bowel now has scar tissue that makes a repeat obstruction highly likely. Knowing the person’s normal bowel habits and responding quickly when they vary is important when factors like medications and immobility cannot be improved. Also important is training direct care providers to recognize and respond to the signs and symptoms the person exhibits when going into a pattern of impaction or obstruction. These can include loss of appetite, abdominal bloating or distention, and complaints of significant abdominal pain. Behavioral signs, including irritability and self-injury are also not uncommon. While preventing the problem is the most desirable, intervening at the earliest possible sign of a problem is essential to a successful outcome.

High Fiber Fruit Butter & Trail Mix Recipe

Here are some of the recipes we’ve recommended over the years to enhance the fiber intake of family, friends, colleagues and the individuals they serve. They are quite tasty and can be used in a variety of ways.

Be sure to encourage extra fluids and do not increase daily fiber intake by more than 6-7 grams/day for each two week period. For example, if baseline is 8-10 grams per day, go to 14-16 per day for two weeks and then bounce up to 20-22 for the next two weeks and then to 26-28 for another two weeks. For each 6-7 grams of fiber increase, add another 8 ounces of non-dehydrating fluid.

The Fruit Butter recipe has been around for quite some time. It is very adaptable and can be eaten with a spoon, spread on toast or bread, mixed in with applesauce or pudding or served warm over oatmeal or ice cream. It can even be mixed with lemonade or another juice and frozen to make popsicles. The limit is only your culinary imagination

Fruit Butter

1. 2 cups raisins
2. 3¼ cup prunes with juice
3. ¼ cup honey
4. 1 tsp. vanilla
5. ½ cup apple juice
6. Soak overnight, then drain, place in food processor for 3 minutes
7. Serving size-2 ½ ounces daily in the morning

Servings per batch: 16 servings @ 8 grams of fiber per serving

Trail Mix

This trail mix recipe was created circa 2006 when Karen Green McGowan and her associate were doing a sweeping round of bowel training for one of their state clients. So many high fiber foods are not particularly palatable to those who most need them. We carried this around to all of our training sessions for several years and can report that almost everyone LOVES it and they experienced the desired effect of enhanced fiber intake!

1. 2 cups raisins
2. 1 lb. raw almonds
3. 1 lb. raw walnuts or pecans
4. 2 cups raisins
5. 2 cups dried cranberries
6. 2 cups unsweetened coconut flakes
7. 1 box Fiber One cereal
8. 1 box Fiber One Honey Clusters cereal
9. 1 bag bittersweet chocolate chips

This recipe can be altered according to taste or for those who are allergic to any of the ingredients. Make sure that any replacement ingredients used are also high in fiber. This recipe makes a very large batch and freezes very nicely.

Two ounces contains 6 or 7 grams of fiber.

We often get this question with regard to the applicability of the HRST: How young is too young? The answer is simple; there is no age limit. The HRST rating criteria applies from womb to tomb. In this brief article we will quickly cover how this works.The HRST does not recognize or acknowledge the concept of normal vs. abnormal. It simply does not apply here. What matters to a SCREENING instrument is the presence or absence of certain factors, not their source. That territory is covered by any necessary assessment and will be addressed when the team consults the HRST Service and Training Considerations. For the purposes of rating we only ask ourselves whether or not a particular situation exists and then subsequently determine risk.

Children, by the very nature of having not yet acquired full physical or cognitive skill development, are at higher risk. Typically developing children will eventually “age out” of the severity of these risks due to skill acquisition. Nevertheless, until that happens the risks are very much present and real. For children who, due to a condition or intellectual and developmental disability, do not eventually acquire these skills, the risks often do not diminish and may never go away. Instead these risks may remain indefinitely and at times even increase. Unlike children who age-out of certain risks and thereby lower their HRST score over time, children for whom the risk factors remain due to developmental issues will likely retain HRST scores accordingly.

Let’s look at several items on the HRST that apply to infants and children, regardless of if or where they fall on the developmental spectrum. Keep in mind that in either situation described above, when the risks are present regardless of the reason, cause, or age the risks must not only be identified but also addressed as effectively as possible.

Children, by the very nature of having not yet acquired full physical or cognitive skill development, are at higher risk.

A. Eating: All infants begin life on an altered-textured diet, both for safety and nutritional reasons. This lasts the majority of the first year of life, after which they should progress to regularly textured items. The HRST scoring for this item would reflect the risks that are involved as a result of eating altered-textured food. If the child were entirely fed via feeding tube or other external source, this would increase the score. These risks remain very real for adults who also need assistance eating, altered-textured diets, or are fed by tube.

B. Ambulation: No child under the age of around twelve years old should score a 0 on this item, which indicates no risk is identified. Most infants do not walk until they are around one year of age. Infants under eight months of age usually require outside support to sit. Children up to a fairly advanced age require supervision with walking for safety reasons, like avoidance of cross-traffic. Ambulation scores for even typically developing children will be triggered depending upon their specific needs. Children, or any adult, who cannot be placed in an upright sitting position regardless of adaptation are assigned the maximum score for this item.

C. Transfer: A slightly tougher item than ambulation, but again, it will rarely rate a score of 0 (noting no identified risk) until well after the first year of life is completed. Early in life children can usually be moved about with the physical assistance of a single caregiver. For safety reasons they require assistance and supervision with things like stairs, uneven surfaces and getting in and out of the bath or shower for several years. Infants and children should always trigger a score in this item until they develop both the physical ability and judgment needed to manage all transfer situations independently. For those individual who do not develop these skills the risks and scores remain.

D. Behaviors: Many children will score in the behavioral section, not because they are bad or poorly parented, but because they lack the formal communication skills and frustration tolerance of adults. Hitting, biting, kicking, cutting hair, and painting walls, etc., happens often and it qualifies for scoring. If physical restraint use applies, and it often does, it should be included, as should any medications used. Again, for some these behaviors may not disappear but remain along with the associated risks.

E. Gastrointestinal Issues: Although spitting up after meals is not uncommon in infants under one year of age it still presents certain risks. These risks, such as aspiration, choking, or esophageal damage are very real for the individual regardless of age.

F. Skin Integrity: Continuous incontinence is an issue that is associated with skin vulnerability. This will earn any child a higher score until they are potty-trained, no longer requiring skin monitoring. If other issues related to skin apply,they should be considered as well. These risk do not go away with age as long as the condition causing incontinence remains.

G. Safety: According to the CDC the single most common cause of preventable death in individuals younger than 45 years of age is accidental injury. Depending upon age bracket, injuries related to falls are either the number one or two cause of emergency room visits across the age spectrum. While we do not advocate rating every trivial scratch or bump, if an injury requires first aid or medical attention it should be captured here, as should falls or near-falls. These serve as indicators of other, often hidden, issues.

In order to thrive and reach their full potential, children require protection and support for many years after birth. Just because these needs are part of the typical developmental process does not mean they do not pose risks and cannot be captured on a screening instrument like the HRST. We strongly encourage our users to think in terms of what is needed, not what is “normal” for the person.

The tool should be applied to children exactly as it is to adults, with the exception of frequency of review. This is due to the rate of expected, normal developmental changes. If the child is under two years of age, the tool should be reviewed quarterly. From ages two to five, the frequency should be semi-annually. From six and above, the normal annual schedule may be observed. 

This should be a question we all ask ourselves on a daily, or more frequent, basis. I say “more frequently” because sometimes we lose sight of what is really important in our jobs.

Completing the program plans, the data collection forms, the medical visit follow-ups, the day-to-day operation of any home, managing behaviors, administering medications-the list goes on and on of the responsibilities in any given day. But, somewhere along the way, the person we are providing services for gets lost in all of it. One on my co-workers says, “You get lost in the weeds” meaning we canlt see above all of that “stuff.” Yes, it’s important “stuff”, but I wager the person’s quality of life and quality of health is a lot more important than some of that “stuff” we deal with daily.

Unfortunately, many of the paid and unpaid staff supporting individuals with disabilities do not think that they are important enough, knowledgeable enough or strong enough to advocate for an individual. YOU ARE! No matter where you fit in an organization, or even if you don’t work with individuals with disabilities, you can advocate. Advocacy is standing up for what is right for a person, speaking up for a person when they can’t, or defending a person.

Advocacy is standing up for what is right for a person, speaking up for a person when they can’t, or defending a person.

Transform all of that “stuff” into advocacy. How can you advocate for a person to help them not get yet another psychotropic medication? You must not be afraid to speak up. If the person has a new onset negative behavior, they are urinating frequently, they are incontinent of urine, the urine smells bad and the color is dark and the doctor wants to order another behavior med to treat the behavior, is that right? It shouldn’t be. We should be advocating for the person to have testing to see if they have a urinary tract infection. You don’t have to be aggressive, but you do need to be assertive and not afraid.

You could say, “Doctor, this new behavior started at the same time as XYZ symptoms. What do think about testing for ABC or could you help us get a referral to DEF?” Maybe the person needs a swallowing study because they are coughing at meals or a referral to a speech therapist. Maybe they are angry because of falling more and becoming more dependent on caregivers. That individual might benefit from a complete physical to look for medical causes of the falls or referral to a physical or occupational therapist. “If you see something, say something”. It doesn’t matter if it is bullying, abuse, neglect or using the “R” word. Advocacy is everyone’s job. Please don’t think of yourself as someone who just provides personal care, passes meds or cooks a meal. Don’t think that you can’t make a difference. You can!

There is a short story of a young boy and an old man walking along a beach covered with starfish. The little boy started picking them up one by one and putting them back in the ocean. The older man said “Son, you’re not going to make any difference with all of these starfish.” As the little boy put one more back in the ocean, he said “I made a difference to that one.”

vThat’s all I ask of you this month: just make a difference to one.