MORE ABOUT THE HRST

Why the HRST?

Most folks in human services, particularly those that work with people with communication challenges, have learned the hard way, that not paying attention to small but growing changes in a person’s physical condition can be very unwise. This cannot only lead to deterioration of function, but can sometimes directly contribute to a preventable death. This unfortunate trend has been demonstrated in a number of states, where health services have been inadequate, and the client death rates have escalated to unacceptable levels. This is true in developmental disabilities, mental health and aging. Also in managed care for individuals without special needs, ignoring certain signs and symptoms can have disastrous consequences.

Although the HRST was developed specifically for a population with developmental disabilities, it is used in persons with psychiatric difficulties, due to the side effects of psychiatric drugs, which can have significant side effects on the function of the human body. Aging is another human condition which has increased health risk and which is managed well using the Health Risk Screening Tool.

The Web-based HRST allows a state or organization to develop a health baseline on all of the individuals in its services. The initial ratings for a group serve the purposes of developing a health baseline and determining the range of clinical supports, services and surveillance needs. Each individual is assigned a health risk score, ranging from one to six. Persons at level one or two are low risk and need relatively few supports. Levels three and four have moderate health risk and need enhanced supports. Levels five and six are high health risk, and need daily to 24-hour professional health supports.

Many individuals who look fragile are really not, and are getting more support than they need, so it is possible to reduce the amount and expense of professional health care support without affecting health and safety.

On the other hand, many individuals who appear healthy are much more unstable than they seem. This is particularly true of persons who get a lot of psychoactive drugs or drugs that affect vital parts of the body, notably the respiratory and cardiac systems. For instance, psychiatric drugs’ most common side effect is constipation. This is difficult for a person to communicate when they cannot talk, and many deaths from bowel obstruction have occurred because this problem was not identified early enough.

The tool is reviewed and redone when individuals status changes, such as ER visits or hospitalizations, f requent changes in drugs, the use of particular drugs, and new medical diagnoses.

Ratings are also done at least annually, to assure that the individual’s health is stable. These annual ratings allow managers to check on the health stability of populations, and scores can be tracked by region, provider, case manager or individual residential setting. Health changes due to poor management can often be identified this way.

A person who has been hospitalized for a bowel obstruction, uncontrolled seizures, or other serious medical condition, will move up to a much higher health risk level for at least 12 months following the event, and protocols require health care surveillance at a much higher level until the person stabilizes.

Primary Mission is Health Surveillance

The HRST is a screening device for detecting health destabilization in a vulnerable population. It was designed to prevent preventable deaths. Persons with psychiatric issues, persons who are older and persons with developmental disabilities have higher than average health care risk. Because these groups are prescribed a number of medications with dangerous side effects, they are often at risk for conditions that are a direct result of the medications themselves and some of these can be life threatening. In one state with a disturbing death rate in its psychiatric facilities, it was discovered that an inordinate number of these deaths were from bowel obstruction, which was likely a direct result of psychiatric drugs and diets that were very low in fluid and fiber.

When to Complete the HRST

At a minimum, each person should have an HRST completed at the time services are initiated and then annually thereafter. It should be completed early in the information-gathering phase of yearly INDIVIDUAL SUPPORT PLAN (ISP) development. The HRST individually identifies health risks as well as the severity of the person’s overall health risk status. This information, derived from the HRST, then guides the Support Team in assuring appropriate assessments, evaluations, services and staff training are addressed in the support planning process.

The HRST is a functional document, to be incorporated into the ongoing health care surveillance process. It should be completed when the person experiences significant health events or changes in health, functional or behavioral status. Examples include but are not limited to: after hospitalizations or emergency room visits; changes in behavioral patterns or trends; changes or losses in functional abilities or skills; changes in health patterns or trends; increased frequency of health complaints, visits by nurse or visits to PCP, etc.

Evaluation, Service and Training Requirements

Another functional use of the instrument is to determine the types of further assessment and evaluation required by the person to be safe and healthy in a less restrictive environment.

The HRST is used in a number of states (Tennessee, Oklahoma, Florida) to determine the type and extent of professional support and training and its use is mandated by policy. In Tennessee, the Division of Mental Retardation Services (DMRS) requires that all recipients of residential services in the department receive a health care level determination using the Health Risk Screening Tool.

In the state of Oklahoma, the Developmental Disabilities Services Division has incorporated the use of the HRST(known there as the Physical Status Review or PSR) as part of the health care policy ( OAC 340:100-5-26). In Florida, the HRST has been incorporated as part of the Status Tracking System and will assist in directing Medicaid waiver supports as well as quality monitoring systems.

This instrument was developed for use by non-licensed staff, such as case managers and independent support coordinators, program staff and others who directly impact services.

Facility Oversight

Within the HRST rating areas themselves are 106 discrete data points. A manager can tell, for instance, exactly how many of his/her clients are receiving certain medications, or have feeding tubes or who require lifting equipment, or who have gotten better or worse over the rating periods.

Additionally, there are good reasons to have the ability to look at the health status of individuals in a region, or served by a provider of residential or day services. One of the most important is that costs can be allocated for persons who really need a higher rate, rather than assuming that high rates are needed for persons simply because they are in wheelchairs, or look like they are medically complex.

When health status begins to deteriorate in a group, one should begin to look at facility management, because when management is not as it should be, the outcome can be deterioration in the health and safely of the persons served. This can be particularly problematic when there is excessive turnover, or a failure to access appropriate health care services.

In summary, the oversight capabilities provided by the HRST offer a tremendous means of assisting the Quality Assurance and Piece of Mind for a provider in an extended facility.