Health Support Plans

Participant Support Procedures > Health Support Plans

Authorised by Chief Executive Officer

Revised date: 10 July 2023

Review date: 10 July 2024

This procedure explains how Kyeema Support Services will implement the disability-related health supports to participants. Kyeema aims to ensure participants receive the health supports they need as a regular part of their daily life.

This procedure supports Kyeema Support Services to apply Standard 3: Provision of Supports – Responsive Support Provision and 4: Provisions of Supports Environment - High Intensity Daily Personal Activities Module

Related legislation and policy

Disability Discrimination Act 1992

United Nations Convention on The Rights of Persons with Disabilities

National Standards for Disability Services

National Disability Insurance Scheme Act 2013

NDIS Quality and Safeguarding Practice Standards 2021

NDIS Practice Standards: High intensity support skill descriptors v3

NDIS (Quality Indicators) Guidelines 2021

Definitions

High Intensity Support Skill Descriptor

The high intensity support skills descriptors (skills descriptors) are for providers and workers supporting participants with high intensity daily personal activities (HIDPA).

A support is considered a high intensity support if the participant requires assistance from a support worker with additional qualifications and experience relevant to the participant’s complex needs.These supports present some of the highest risks for participants.

High intensity support skill descriptors:

• Complex Bowel Care

• Enteral Feeding Support

• Dysphagia Supports

• Ventilator Support

• Tracheostomy Support

• Urinary Catheter Support

• Subcutaneous Injections

• Complex Wound Care Support

Additional support activities:

• Epilepsy & Seizure Support

Disability-related Health Supports directly relate to a participant's significant and permanent functional impairment and. assist them to undertake activities of daily living.

• Dysphagia: for participants who have trouble eating, drinking or swallowing on a daily basis

• Respiratory: for participants requiring help with their care and planning to help them breathe and maintain respiratory health where this is compromised.

• Nutrition: for participants requiring help with the way they eat or understanding the food they need

• Diabetes management supports: for participants who need extra help to manage their diabetes, for example, testing their blood sugar level because they are unable to do this on their own due to the functional impact of their disability.

• Continence supports: for participants who need products to maintain your continence or someone to help them with toileting on a daily basis.

• Wound & pressure care supports: for participants who have slow to heal wounds, a condition that results in swollen arms or legs, or ongoing loss of feeling in their body or arms or legs, and they need regular skin, wound and pressure care.

• Podiatry supports: for participants who need assessment and development of a care plan to help look after their feet, ankles and lower limbs.

• Epilepsy supports: for participants who need help to monitor and manage seizures when they occur.

https://www.ndis.gov.au/about-us/operational-guidelines/disability-related-health-supports-operational-guideline/disability-related-health-supports-operational-guideline-breakdown-disability-related-health-supports

Procedure

When a person first uses Kyeema services, information about any medical supports will be added to the person’s service record. This includes information about the type of support, process, frequency, dosage and any other relevant information.

Any instructions on how to provide the direct health support must be kept with the medication/equipment and on the person’s file.

The manager is responsible for ensuring the workers providing the support are trained and competent to provide the relevant health support. High Intensity supports require workers to be specifically trained.

All workers responsible for administering medication to be aware that:

- some medications may have side-effects and

- steps may need to be taken in the event of an incident involving medication.

If a trained worker is unavailable, Kyeema will support the person to seek medical services such as a nurse or doctor.

If a person accessing Kyeema services develops/acquires a new health condition that requires ongoing health support, the person will be required to undertake a health needs assessment by a qualified medical professional before Kyeema can provide health supports.

The coordinator/team leader will ensure that the person’s health support plans are up to date and available in the person’s medical records. This should include:

• information about their communication needs

• names and contact details of those involved in their health care. This should include primary care providers, specialists and those involved in health care decisions (including details of next of kin)

• relevant medical history, including information about their disability, pre-existing health issues (especially respiratory and heart conditions) and current medications administered by Kyeema

• a current advanced care directive or plan if appropriate

• the person’s mental health and/or Positive Behaviour Support plan, if they have one

• evidence that the participants health support plan has been read by support workers

Support Planning Flowcharts

CCF – 84 Support Planning Process – NDIS Documentation Flowchart

CCF – 85 Support Planning Process – TAC Documentation Flowchart

Participant Health Support Files can include high intensity support needs (eg complex bowel care, urinary catheter support and dysphagia support) and general supports. The files may be in different formats such as:

• CCF Health Support Plan templates

• Medical forms from doctor and allied health professionals

• Forms from residential providers

Health support templates available for use in addition to medical forms from allied health professionals and/or residential providers

• Health Support Plan – Asthma CCF- 35

• Health Support Plan – Seizure CCF- 42

• Health Support Plan – General CCF- 44

• Health Support Plan – Epilepsy CCF- 46

• Epilepsy Medication Management Plan (Midazolam) CCF-47

• Health Support Plan – Enteral Feeding CCF- 49

• Health Support Plan – Catheter Care CCF- 50

• Health Support Plan – Diabetes CCF- 56

• Health Support Plan – Bowel Care CCF- 81

• Health Support Plan – Mental Health CCF- 82

• Health Support Plan – Mealtime Management or Dysphagia Support CCF-83

Support types

Continence supports

o A suitably qualified and competent worker to provide catheter maintenance and care; to provide assistance to manage bowel care where needed; stoma management and care

Diabetic management supports

o Development of a specific diabetes management plan where the participant’s disability complicates the management and care of their diabetes. This would build on the clinical plan developed by the General Practitioner.

o Implementation of a diabetic management plan and daily maintenance and care by a suitably qualified and competent worker.

Dysphagia Supports

o Development and periodic review of a mealtime management plan by a suitably qualified and competent clinician.

o Development, implementation and periodic review of an oral eating and drinking care plan (OEDCP) by a suitably qualified and competent clinician.

o Swallowing therapy associated with dysphagia provided by a suitably qualified and competent worker.

o Practice Alert Dysphagia

o Practice Alert Medicines associated with swallowing problems

Epilepsy supports

o Training of a suitably qualified and competent worker to implement the participant’s Epilepsy Management Plan (EMP) and/or Emergency Medication Management Plan (EMMP).

o Epilepsy seizure monitoring by a suitably qualified and competent worker including the application of assistive technology.

o Practice Alert Epilepsy

Nutrition supports

o Dietetic consultations and the development and periodic review of a nutritional meal plan by a suitably qualified and competent clinician.

o Implementation of a nutritional meal plan by a suitably qualified and competent worker.

o Percutaneous Endoscopic Gastrostomy (PEG) Stoma Changes (to assist feeding) by a suitably qualified and competent clinician.

o Provision of PEG maintenance and care by a suitably qualified and competent worker.

Podiatry supports

o Assessment, development, implementation and periodic review of a podiatry care plan by a suitably qualified and competent clinician.

Respiratory Supports

o Development and periodic review of a care plan for the daily maintenance of tracheostomy (insertion, removal and change) by a suitably qualified and competent clinician.

o Provision of a ventilator, air humidifier, portable suction machine and/or cough assist machine and consumables.

o Assistance with the use of all respiratory medical equipment as well as the training of a suitably qualified and competent worker to use the equipment.

Wound and pressure care supports

o Development of a care plan by a suitably qualified and competent clinician.

o Wound care and pressure care (including pressure injury management) by a suitably qualified and competent worker.

o Training of support workers/families in prevention of pressure areas and wounds.

Training

Sentrient is the learning management system used for Kyeema workers.

Trained, skilled and competent workers must provide direct health supports for people with disability. Specific training is required for the high intensity supports such as complex bowel care and urinary catheter support.

Dysphagia support workers are to be trained by a speech pathologist. Each high intensity worker will have an individual training plan and annual skills review.

Review and Evaluation

Team Leader to check that plans are up to date and contact relevant people if the support plan is outdated.

The diagram below demonstrates the different planning and reporting responsibilities of disability service providers in relation to:

1. meeting the healthcare of the people they support

2. managing the person’s behaviour

Source: Chemical restraint of people with a disability: guide and form DFFH

Responsibilities

Any mistake or error in providing direct health supports is reported immediately to the supervisor and the Incident Reporting Policy and Procedure followed.

Record keeping

Workers

Kyeema maintains a database of trained workers and the direct health supports they are trained to provide.

• Sentrient LMS

• K-drive\General Items for All Staff\Databases\Staff Training Database (archived records)

Participants health support plans

Hard copy:

• Participant health support plans are kept in the participants file in the locked filing cabinet

• Evidence that workers have read the health support plans are kept with the participant files

Electronic copy: K-drive\Client or Participants\Adult

• Go to adults name

• Go to health folder