Improving capacity to care for patients with intellectual and developmental disabilities: The value of an experiential learning model for family medicine residents.

BACKGROUND: Patients with intellectual and developmental disabilities (IDD) are more likely to experience poor health outcomes and family physicians receive inadequate training to provide appropriate care to this patient group. Little prior research has studied how to effectively train family physicians to care for patients with IDD. OBJECTIVE: The aim of this pilot study was to assess the value of adding an experiential component to didactic education strategies to improve family medicine resident perceived comfort, skills and knowledge related to caring for patients with IDD. METHODS: Structured education programs for residents were implemented at three primary care practices in Ontario, Canada. Two practices received didactic information only (didactic-only group); one received didactic information and an experiential training model including clinical interactions and a written reflection on that experience (didactic plus experiential group). In this separate-sample pre-post design, residents were invited to complete a brief anonymous survey prior to and following the training assessing their perceived comfort, skills and knowledge related to patients with IDD. RESULTS: At baseline, there were no significant differences between the two groups of residents. At follow up, the experiential group reported significantly higher levels of comfort, skills, and knowledge compared to baseline for most items assessed, while in the didactic-only group most items showed little or no improvement. CONCLUSION: This pilot study suggests that providing residents the opportunity to participate in clinical encounters with patients with IDD, as well as a structured process to reflect on such encounters, results in greater benefit than didactic training alone.

Enhanced skills training in family medicine maternity care: Cross-sectional study of graduates' experiences.

OBJECTIVE: To describe the experiences of participants in Canadian family medicine maternity care enhanced skills programs: their current practice situation with respect to maternity care; the reasons they pursued enhanced maternity care training; and their perceptions of competencies attained during the program. DESIGN: Cross-sectional questionnaire. SETTING: Canada. PARTICIPANTS: Graduates of family medicine enhanced skills programs in maternity care in Canada between 2004 and 2014. MAIN OUTCOME MEASURES: Participants' current engagement in intrapartum care; reasons for participating in the enhanced skills programs; interest in obstetrics at different points in training; and development of maternity care competencies during both core residency and the enhanced skills program. RESULTS: Eighty-seven graduates (response rate of 44%) participated. At an average of 5 years in practice, 77% of enhanced skills graduates were providing intrapartum care. Sixty-nine percent of respondents took the enhanced skills program because they did not feel ready to practise obstetrics without supervision. More than half (55%) of respondents had intended to include obstetrics in their future practices when they were in medical school. By the end of residency, 99% intended to practise obstetrics; however, this percentage decreased to 87% by the end of fellowship. There was a statistically significant increase in graduates' perceptions of various maternity care competencies (eg, vacuum-assisted birth, perineal repair) following enhanced skills training. Eighty-two percent of respondents indicated that the ability to access enhanced skills training supported their decision to provide obstetrics care. CONCLUSION: This is the first evaluation of graduates of enhanced skills programs in maternity care in Canada. Enhanced skills programs appear to support the education of family medicine maternity care providers; however, these programs might be compensating for residents' lack of confidence in providing maternity care independently rather than providing truly enhanced skills. This study also confirms that some medical students and family medicine residents change their minds in the direction of wanting to provide full-scope maternity care during the course of their education.

Teaching family medicine residents about care of adults with intellectual and developmental disabilities.

PROBLEM ADDRESSED: Adults with intellectual and developmental disabilities (IDD), a group with complex health problems and inequities in access to health care, look to family physicians for primary care. OBJECTIVE OF PROGRAM: To enable residents to learn and demonstrate competencies that are unique to the care of adults with IDD with minimal extra time and resources required of the residency program. PROGRAM DESCRIPTION: In their regular family medicine teaching practices, residents undertake planned encounters with adults with IDD involving comprehensive health assessments with physical examinations. Tools to implement the Canadian guidelines for primary care of adults with IDD are available to support the residents in their encounters. Background information in the form of self-learning and small group learning resources, field notes with rubrics to assess residents' development of competencies, and faculty development resources are also available. CONCLUSION: It is important to include such planned clinical experiences in family medicine residency curricula because people with IDD have special needs that are difficult to learn about in other settings. It is a benefit to residents to have patients and families actively contributing to teaching.

Primary care of adults with intellectual and developmental disabilities: 2018 Canadian consensus guidelines.

OBJECTIVE: To update the 2011 Canadian guidelines for primary care of adults with intellectual and developmental disabilities (IDD). METHODS: Family physicians and other health professionals experienced in the care of people with IDD reviewed and synthesized recent empirical, ecosystem, expert, and experiential knowledge. A system was developed to grade the strength of recommendations. RECOMMENDATIONS: Adults with IDD are a heterogeneous group of patients and have health conditions and factors affecting their health that can vary in kind, manifestation, severity, or complexity from those of others in the community. They require approaches to care and interventions that are adapted to their needs. These guidelines provide advice regarding standards of care. References to clinical tools and other practical resources are incorporated. The approaches to care that are outlined here can be applied to other groups of patients that have impairments in cognitive, communicative, or other adaptive functioning. CONCLUSION: As primary care providers, family physicians play a vital role in promoting the health and well-being of adults with IDD. These guidelines can aid their decision making with patients and caregivers.

Soins primaires aux adultes ayant des déficiences intellectuelles et développementales: Lignes directrices consensuelles canadiennes de 2018.

OBJECTIF: Mettre à jour les Lignes directrices consensuelles canadiennes 2011 en matière de soins primaires aux adultes ayant une déficience développementale. MÉTHODES: Des médecins de famille et d'autres professionnels de la santé expérimentés dans les soins aux personnes ayant des DID ont examiné et synthétisé les récentes connaissances empiriques, d'écosystèmes, expertes et expérientielles. Un système a été conçu pour catégoriser la qualité des recommandations. RECOMMANDATIONS: Les adultes ayant des DID sont un groupe hétérogène de patients qui présentent des affections médicales et des facteurs qui influent sur leur santé, qui diffèrent de ceux qui touchent les autres membres de la communauté de par leur nature, leurs manifestations, leur gravité ou leur complexité. Ces personnes nécessitent une approche de soins et des interventions adaptées à leurs besoins. Les présentes lignes directrices offrent des conseils en matière de normes de soins. Nous avons incorporé des références à des outils cliniques et à d'autres ressources pratiques. Les approches de soins décrites ici s'appliquent aussi à d'autres groupes de patients ayant un déficit cognitif ou de la communication, ou d'autres déficits des fonctions adaptatives. CONCLUSION: À titre de fournisseurs de soins de première ligne, les médecins de famille jouent un rôle vital de promotion de la santé et de bien-être auprès des adultes ayant des DID. Ces lignes directrices peuvent les aider à prendre des décisions avec les patients et les aidants naturels.

Managing complexity in care of patients with intellectual and developmental disabilities: Natural fit for the family physician as an expert generalist.

OBJECTIVE: To delineate the factors inherent in caring for patients with intellectual and developmental disabilities (IDD) that lead to complexity and to provide perspectives and techniques mapped to the phases of the clinical encounter. SOURCES OF INFORMATION: The authors of the physical health section of the 2018 Canadian consensus guidelines on the primary care of adults with IDD consisted of family physicians, all of whom practise comprehensive family medicine with additional clinical experience in care of adults with IDD. These authors reviewed evidence on which their recommendations are based and these recommendations have undergone a rigorous peer review to ensure that they deserve special attention because they highlight what is different from what a family physician would consider to constitute "normal care" for the general population. MAIN MESSAGE: Additional factors across the phases of clinical encounters with patients with IDD include the need for the following: an initial assessment that identifies genetic or neurologic conditions to guide anticipatory care and isolates unique barriers to health promotion and chronic disease management; adaptations to history taking, particularly for patients who are unable to describe symptoms owing to cognitive and communication deficits; overcoming challenges to performing physical examinations and certain investigations; addressing uncertainty in the formulation of hypotheses to establish an appropriate diagnosis; and involvement of resources of the developmental services sector to provide a management plan as well as an adapted empathetic approach in order to integrate the patient's illness experience. CONCLUSION: Although each patient with IDD is unique, and care of patients with IDD requires knowledge of certain conditions, these considerations are readily identifiable, and family physicians as expert generalists are well equipped to provide excellent care to patients with IDD.

Improving transition to adulthood for adolescents with intellectual and developmental disabilities: Proactive developmental and systems perspective.

OBJECTIVE: To demonstrate how family physicians can contribute to a piece of the journey of improving quality-of-life outcomes for people with intellectual and developmental disabilities (IDD) when they undergo the transition from adolescence to adulthood. SOURCES OF INFORMATION: The "Primary care of adults with intellectual and developmental disabilities. 2018 Canadian consensus guidelines" literature review and interdisciplinary input. MAIN MESSAGE: Family physicians should be proactive in anticipating and supporting the transition of people with IDD from adolescence to adulthood. Interventions should be guided by a developmental perspective regarding the person with IDD and a life-cycle approach to supporting families. Family physicians also have a role in helping people with IDD and their families to navigate successfully through changing community-based support systems in their province, especially health care and social services systems. Therefore, family physicians should be aware of current services available in their regions. CONCLUSION: Community and team-based family physicians can optimize the quality of life of people with IDD and their families by adopting a proactive developmental and systems approach to preparing youth with IDD for adulthood. In doing so, they exemplify the 4 principles of family medicine.

Circles of care for people with intellectual and developmental disabilities: Communication, collaboration, and coordination.

OBJECTIVE: To review health information exchange (HIE) processes that affect the health of people with intellectual and developmental disabilities (IDD) and to suggest practical tips and strategies for communicating, collaborating, and coordinating in the primary care setting. SOURCES OF INFORMATION: The "Primary care of adults with intellectual and developmental disabilities. 2018 Canadian consensus guidelines" literature review and interdisciplinary input. MAIN MESSAGE: Disparities exist between the provision of health care for the general population and that for people with IDD. These disparities are due in part to gaps in HIE. Health information exchange involves documenting, collecting, and disseminating a patient's health information. In exploring ways to improve HIE for people with IDD, the communication skills of the family physician are considered in the context of the triad that includes the patient, his or her caregivers, and the family physician. The framework of the Patient's Medical Home is used in exploring these processes, and various strategies are offered for communicating, collaborating, and coordinating health care that can be implemented by family physicians in order to narrow the gaps in care that exist for people with IDD. CONCLUSION: Improvements in HIE by communicating, collaborating, and coordinating health care better will improve health outcomes for people with IDD.

Review of gynecologic and reproductive care for women with developmental disabilities.

PURPOSE OF REVIEW: Care for women with developmental disabilities requires special consideration for unique needs related to their cognitive and physical abilities. These women and their caregivers require more support and guidance during reproductive health care. We review the literature and provide expert opinion surrounding gynecological issues for women with developmental disabilities to support healthcare providers better understand and care for this population. RECENT FINDINGS: Women with developmental disabilities are more vulnerable to abuse and experience poorer gynecological healthcare outcomes. Many women with developmental disabilities are fertile and participate in sexual activity without adequate knowledge. They are at higher risk of pregnancy and birth complications. They are less likely to receive appropriate preventive screening. SUMMARY: The review highlights important issues and practice suggestions related to the reproductive health care of women with developmental disabilities. Topics include clinic visits, menstruation, sexuality, sexual abuse, sexual health education, contraception, sexually transmitted infections, pregnancy, labor and delivery, and cancer screening/prevention. We emphasize the need for an individualized, comprehensive approach for these patients and review perceived and actual barriers to care. More education is needed on the aforementioned topics for women with developmental disabilities, their caregivers, and their providers.