Service overview

Objective of the service

• People with intellectual disability have access to coordinated health care in the community that responds to their health needs in a way that is respectful and inclusive.
• People with intellectual disability have confidence that their health care and health related disability needs are being met by NSW Health staff and the broader health system.
• NSW Health staff and the broader health system have increased confidence, skills and collaborative relationships with other services to support people with intellectual disability.

Structure of the service

The IDHS is made up of a network of Teams and Positions across NSW.

What the service delivers

The IDHS delivers:

• Comprehensive health assessment and time-limited clinical service for people with intellectual disability who a health need that has not been addressed by their current care team and the local mainstream services system.
• Activities to build the capability, skills, knowledge, values and experience of NSW Health, primary health, and student/trainee health staff to respond to the care needs of people with intellectual disability.

The IDHS does not provide:

• Routine reviews or ongoing care.
• Ongoing responsibility/case management services for clients.
• After-hours requests responses – the IDHS is an office hours service that cannot respond to after-hours requests. Referrers are advised to implement usual after-hours crisis response, e.g., ED presentation or Mental Health Line. A referral to the IDHS may be appropriate in parallel with a crisis response.
• Diagnostic assessments to diagnose intellectual disability or autism spectrum disorder.
• Applications to the National Disability Insurance Scheme (NDIS) – however, the IDHS can provide advice and documentation to support this process. 

Who is the service for?

Individuals are eligible for the IDHS when they have:

• Intellectual disability or suspected (unconfirmed) intellectual disability where there is substantial evidence to support this (including anecdotal evidence) and
• A general practitioner (or other medical specialist, e.g., paediatrician) who can implement the care plan recommendations and follow through with care, and
• A complex or chronic health condition, or
• their current health care team need specific advice on tailored support so they can provide reasonable adjustment for the patient with intellectual disability, or
• their current health care team need specific advice on clinical considerations related to the client's complexity, or
• Complex circumstances, e.g., relating to stability of care and supports, socio-economic status, social isolation and/or experience of trauma.

A formal, documented diagnosis of intellectual disability is not required for the IDHS to accept a referral where there is sufficient clinical and other evidence of intellectual disability.

The client's residential address (or hospital location if client is an inpatient) determines which local health district provides the service. The IDHS can be accessed anywhere in NSW.

Service details

The IDHS provides a comprehensive multidisciplinary assessment and healthcare plan for eligible clients. 

There are six stages to the standard approach:

1. Referral and intake
• Referrals are made by a supporting GP or other medical specialist (e.g., paediatrician) using the referral form or a comprehensive referral letter.
• If the client does not have a GP or equivalent to oversee their health care, the IDHS supports identifying an appropriate GP or equivalent as part of the intake process.
• Referrals are triaged and prioritised according to clinical need and risk assessment.
• Consent to service obtained from client/guardian/person responsible.
• Clients may be asked to complete an assessment questionnaire. The IDHS may provide support to access this information.
2. Consultation
• Person-centred and trauma informed– clients and their care providers are asked about communication needs, social history, expectations
• Collaborative consultations – where appropriate, and with consent, other health care providers (e.g., GP, paediatrician, allied health care providers), school staff, support workers, NDIS service providers.
• Assessment of a client’s physical, mental, and psychosocial health and medical examination if required.
• Consultations may be virtual (if appropriate) or in -person.
• Consultations identify client’s health care needs and gaps in services/supports.
3. Report and healthcare plan (with recommendations)
• Together with the client and their family/carer, a detailed healthcare plan is developed based on a report which summarises the assessment.
• The IDHS provides the client (and as appropriate, and with consent) their carer and family, treating team and GP with a copy of the healthcare plan and report.
• The IDHS may contact the referrer and/or other health/disability professionals to discuss the recommendations/care plan.
• The IDHS contacts other health/disability professionals to discuss the healthcare plan and report.
• The healthcare plan may include:
• Referral to other specialist health services (e.g., endocrinology, mental health, allied health)
• Referral for other assessments (e.g., sensory assessment, behavioural assessment, speech pathologist assessment, Occupational Therapist assessment)
• Recommendations on implementation of the healthcare plan by primary care providers including changes to medication, dietary recommendations, physical activity recommendations
• Advice on other community and/or disability services e.g. day program, peer support group
• Advice on strategies to provide appropriate ongoing care.
4. Time-limited clinical care
• If required, time-limited clinical care (virtual or in person) may be provided by the IDHS e, g. medical, nursing, psychiatric treatment, and/or counselling services.
5. Discharge
• ​The client is discharged from the service when the assessment has been completed, the report and the healthcare plan communicated, and any appropriate referrals made by the IDHS.
• Before discharge the IDHS will advise the client and their carer/family to continue care and follow up with the primary treating clinician/team.
• A discharge letter may also be provided to referrer, client/family and other relevant parties.
6. Follow up                              

Partnership service

IDHS Teams and IDHS Positions provide a statewide service. The IDHS Team and IDHS Positions work collaboratively to deliver a service for patients residing in their partner local health districts.

Capacity building

The IDHS undertake activity to build the skills, knowledge, values and experience of NSW Health staff and mainstream health clinicians in responding to the needs of people with intellectual disability.

Capacity building can include:

• Providing joint consultation, case conferences, and expert advice to NSW Health and primary health clinicians (e.g., GPs and general practice teams) on the assessment and care of people with intellectual disability, to:
• Better understand the needs of people with intellectual disability
• Develop strategies to provide appropriate care, including reasonable adjustments
• Identify pathways and services for people with intellectual disability
• Establishing formal links with mainstream hospital and community-based services, including private practice, emergency departments, allied health, clinical staff, and general practice teams
• Delivering webinars, skills training and other education sessions
• Development and/or promotion of communication resources to support people with intellectual disability (e.g., Easy Read resources)

In addition to building the capability of NSW Health and primary health care providers, the IDHS builds the capacity of people with intellectual disability and their care providers (families/carers/disability support workers). Through consultations and other individual engagement with clients, families and other key stakeholders, the IDHS builds their capacity to navigate and effectively engage with health services and improve health literacy.

As the focus of the IDHS is on delivering a comprehensive assessment service, between 15% to 40% of IDHS time should be allocated to delivering capacity building activities. Capacity-building activities are outlined in each local health district's capacity building plan. Capacity building plans should be reviewed and updated annually The Ministry of Health will ask for evidence of delivery of capacity building activities as part of annual performance discussions.