Facilitating a multidisciplinary approach to care for people with developmental disability

General practitioners (GPs) are well placed to coordinate comprehensive care delivered by medical specialists and other professionals. Taking time to collaboratively develop a GP Management Plan can clarify the roles of team members as well as enhance the GP’s role.

Strategies to facilitate multidisciplinary care for people with developmental disability include:

documenting the person’s specific needs (eg communication support needs, decision making support, behaviour support plan) and highlighting this in referral information
identifying local health and disability services and noting them in the person’s record
ensuring that information from other providers is received and recorded (eg hospital discharge notes, imaging or test results)
conducting regular comprehensive health assessments to identify individual screening needs, necessary reasonable adjustments and opportunities that might enable screening (see opportunistic examinations and procedures)
liaising with disability groups or networks for referral recommendations
allocating a contact person in the GP practice (eg practice manager or nurse) to manage the person’s appointments and ensure the information above is updated regularly; record who this contact person is in the medical record
keeping a record of the person’s current National Disability Insurance Scheme (NDIS) plan.

For useful medical and allied health referrals for people with developmental disability in primary care, see Medical referrals for people with developmental disability and Nursing, allied health and other referrals for people with developmental disability. Some states have specialist intellectual and developmental disability multidisciplinary services or teams; for examples, see Specialist multidisciplinary clinics and services for people with intellectual or developmental disability. These centres differ in the services they offer (eg medical assessments, education and training), but all are resources for GPs.

Medicare items may apply for health assessments and care planning (eg GP Management Plan, Team Care Arrangements) in this group of patients; see here.

Table 1. Medical referrals for people with developmental disability
[NB1]
Professional	Purpose [NB2] [NB3]
paediatrician	detailed assessment of development and disabilities information about diagnosis, cause and implications contribute to care planning, monitoring and periodic review information about child services
geneticist	information about available tests and indications information about cause and genetic implications
psychiatrist	diagnose psychiatric illness, manage treatment and provide a range of therapies for people with dual disability
specialist or general physician	comprehensive assessment and nonsurgical management of adult patients with complex presentations and serious or unusual medical problems; prepare medical management plan
rehabilitation physician	expertise in disability assessment and prevention, and functional rehabilitation pain assessment coordinate multidisciplinary rehabilitation team or program
geriatrician	expertise in care of older people who have multiple and complex conditions
psychogeriatrician	expertise in psychogeriatric care assess functional ability and develop management plan
neurologist	assessment of regression in skills or abilities, or change in neurological status assessment, diagnosis and management of epilepsy, seizures and other neurological disorders
Note: NDIS = National Disability Insurance Scheme NB1: This is not an exhaustive list. NB2: For information on NDIS access to early intervention support, see here. NB3: Some support (eg dysphagia or continence management, behaviour support) may be eligible for NDIS funding; see NDIS.

Table 2. Nursing, allied health and other referrals for people with developmental disability
[NB1]
Professional	Purpose [NB2] [NB3]
psychologist	provide functional assessment—information about the person’s level of intellectual functioning and areas of relative ability and difficulty teach strategies for building adaptive skills advise on managing challenging behaviour assess and treat coexisting psychiatric disorder assist family members in coming to terms with the implications of a child’s disability
behaviour support clinician	provide assessment (eg cognitive, functional, behavioural, risk) and interventions (eg behaviour management plan, education for support people and carers, counselling, cognitive behavioural therapy)
speech pathologist [NB4]	assess speech and language teach strategies to help develop communication skills assess swallowing, and advise on mealtime positioning, and food and fluid texture modification assess and manage augmentative and alternative communication options and training
dietitian [NB4]	assess nutrition (including total kilojoule, food group and micronutrient requirements), particularly for people who are under- or overweight develop nutritional care plans, including caloric supplementation, and food and fluid texture modification provide individual and group dietary counselling
physiotherapist	assess and provide strategies to optimise motor function advise on appropriate aids and equipment (eg for optimal positioning at mealtimes) provide a comprehensive pain assessment
occupational therapist	assess and provide strategies to optimise fine motor and self-care skills (eg eating and drinking techniques) advise on appropriate aids and equipment (eg seating, mealtime aids) provide sensory assessments
dentist, including paediatric or special needs dentist [NB5]	assess and treat oral and dental conditions advise on preventive oral health
genetic counsellor	advise on medical, psychological and familial implications of genetic disorders (eg testing, management, prevention, resources, research) assess and assist families coping with the diagnosis of a genetic disorder
grief counsellor	provide support and strategies for a person dealing with grief or bereavement
pharmacist	perform medication reviews provide support or counselling for patients with a disability who are taking medication
social worker	assess support needs of the person, and family or carers provide assistance in navigating support systems (eg advocacy within the person’s workplace)
practice nurse	plan and provide nursing care, treatment and health education, and assist with medical care in a general practitioner office or group practice update the patient’s medical records to ensure information currency
continence nurse or continence physiotherapist	assess, treat and manage incontinence facilitate pelvic floor rehabilitation determine appropriate continence aids and relevant funding
guardianship tribunal [NB6]	appoint substitute decision makers (eg guardian, administrator) for adults who lack decision-making capacity
NDIS support coordinator	assist a person to understand, implement and use their NDIS plan ensure the person has access to an appropriate combination of supports and services
mental health case manager	assist with illness management and relapse prevention (eg setting and reaching goals, accessing services) while the person is a client of public mental health services
orthotist	assess and treat physical and functional limitations prescribe, design, fit and monitor orthoses
audiologist	assess hearing and hearing disorders provide nonmedical management and rehabilitation of hearing loss
optometrist	assess, diagnose and manage eye and vision disorders; advise on eye care prescribe and dispense glasses and contact lenses
Note: NDIS = National Disability Insurance Scheme NB1: This is not an exhaustive list. NB2: For information on NDIS access to early intervention support, see here. NB3: Some support (eg dysphagia or continence management, behaviour support) may be eligible for NDIS funding; see NDIS. NB4: Speech pathologist and dietitian may collaborate on swallowing assessment and food and fluid texture modification. NB5: Specialist paediatric and special needs dentists have expertise in managing anxiety in people with developmental disability. NB6: State-based civil and administrative tribunal that can appoint substitute decision makers.

Table 3. Specialist multidisciplinary clinics and services for people with intellectual or developmental disability
[NB1] [NB2]
New South Wales
Agency for Clinical Innovation—Intellectual Disability Resources Department of Developmental Disability Neuropsychiatry (3DN) Centre for Disability Studies Intellectual Disability Health Teams—refer to Local Health District websites for Hunter New England, South Western Sydney, Northern Sydney, Sydney, Western New South Wales or South Eastern Sydney Local Health Districts
Queensland
Mater Intellectual and Disability and Autism Services (MIDAS) Queensland Centre for Intellectual and Developmental Disability (QCIDD)
South Australia
Centre for Disability Health (CDH)
Tasmania
Specialised Health Care for Adults with Intellectual Disabilities (SHAID) Clinic, Calvary Hospital
Victoria
Centre for Developmental Disability Health (CDDH) Victorian Dual Disability Service (VDDS)
Note: NB1: This is not an exhaustive list. NB2: Refer to the websites for specific services offered, age groups seen and other details.