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History of the Health Risk Screening Tool

Identification of Need: The Hodges Report

Below is a brief summary of information from the “Hodges Report”, published in 1984 by Brehon Institute for Human Services. The Hodges Report helped to identify the need for an instrument like the HRST and provided some of the early groundwork for its development.

During the years 1982-1984, a number of individuals from the Tallahassee and Orlando Sunland facilities were moved into a series of 3-8 bed units, or clusters, which were designed for individuals defined as “developmental-medical”. These clusters were located at six separate sites around the state of Florida.

In February of 1982, the first death of a client occurred in the Hodges cluster, located in Jacksonville. In the next two months it was followed by three other deaths. By April of 1983, nine individuals from this facility had died. No other facility experienced such a large number of deaths relative to the number of clients it served. In fact, while the death rate at the privately operated clusters was half that of the Sunland facilities, the death rate at the state-run, Hodges cluster was double.

Client characteristics were eliminated as potential causes of death when it was shown that the individuals at the Hodges cluster were LESS medically involved than those at the other sites. Further investigation indicated that management factors were directly related to the causes of death of these individuals. Inadequacies in facility readiness and staff training, as well as other operational problems, were directly implicated in the deaths of the Hodges clients.

The higher death rate at the Hodges cluster was NOT explained by greater fragility or medical complexity of its consumers, but instead by the inadequate care capacity at the cluster that was unable to meet the needs of its consumers. The Hodges cluster had a smaller, less well trained, more unstable labor force than the other clusters, with a higher staff turnover rate and fewer staff available on any given shift. It became clear that management was the key to safety and stability. As a result of this several vital steps to the successful oversight and management of individuals with special needs were identified:

  • Always know if a person’s condition is getting better or worse
  • Have an early warning system to detect destabilization
  • Do not let chronic health issues become routine or invisible
  • Records must provide useful data about trends
  • Ensure continuity of care across providers
  • Monitor residential settings to assure health and safety

Initial Development

The Health Risk Screening Tool (HRST) originated in Oklahoma in the early 90’s as part of a class action court case: Homeward Bound v. Hissom Memorial Center. This case was overseen by a federal judge, James Ellison, in the Northern district of Oklahoma. With nearly 1,100 class members, including a number of children using a range of medical technology, the institution was scheduled to close in 1994. Judge Ellison appointed a nurse to the panel (Karen Green McGowan) to assist him in protecting the health and safety of those class members whose fragile health status was of great concern to him.

The consent decree mandated that no class member could be placed in a residential facility larger than three (3). Further requirements were that the cost of all residential placements could not, on the average, exceed the daily cost at Hissom. A Federal magistrate had been appointed to mediate disagreements between the parties and/or families when there was a dispute as to the type of placement. Most families, particularly those with young children, were used to 24-hour nursing coverage. There was no objective mechanism to measure the fragility of these individuals and so the outcome of the disputes most often went to the families. The cost of nursing coverage for 3 person settings was often doubled in order to fulfill this requirement.

Judge Ellison asked Ms. McGowan to develop a mechanism to measure the fragility of the class members who were rapidly being placed into the community. Most of these individuals were being placed in the Metro-Tulsa area, but 25% of these class members were scheduled to be placed in other areas of the state, most of which were quite rural and devoid of health care supports. At this point, there was one registered nurse serving in each of the state’s three Developmental Disabilities service regions. Health care surveillance for persons with disabilities in the community was nearly non-existent at the time.

Ms. McGowan and the Area II RN, Shirley McKee, brought together a group of nurses along with an out-of-state nurse consultant, to brainstorm for a few days about the requirements for a surveillance process to protect the health and safety of this population. Since nursing supports were nearly non-existent in the three regional systems, the group decided that the tool would need to be used by someone who knew the individuals well, but who had relatively little medical background. Hence, the group that the tool was designed for became the case managers. Case Managers were assigned to community consumers at a ratio of 1:25, and during the first 12 months, 1:10 following transition from Hissom.

Field Testing and Implementation

The original paper tool was known as the Physical Status Review (PSR). This paper instrument was field tested by the RNs in the Oklahoma DD system on some 6000 individuals, including those from the other two state facilities. This allowed for the honing of the instrument on a broad range of individuals with disabilities and resulted in a number of changes to the instrument. At that time there were also efforts to develop a state-wide health care policy, Health Care Policy for DDSD (Developmental Disabilities Services Division). The Health Care Policy for DDSD specified that health supports were tied to Health Care Levels determined by the Physical Status Review (now called the Health Risk Screening Tool).

Health Care Levels were assigned based on points accumulated on the PSR, with Levels I and II being low risk, Levels III and IV being moderate risk, and Levels V and VI being the highest risk. Level VI were the only individuals designated as eligible for 24-hour nursing care. This designation of eligibility based on an objective instrument administered by trained and experienced health care personnel now allowed the state to win its arguments with the Federal Magistrate. This allowed the state to reduce its residential costs to meet the other requirements of the Settlement Agreement. The tool was also used to drive surveillance requirements such as RN review, referral for therapy assessments and medical specialty assessments. Training requirements for staff were additionally delineated by the instrument.

Continued Development and Expansion of Use

The HRST remained paper-based until 1998, when the first attempt at an electronic version was developed in Oklahoma. This was a single-user version that allowed up to 300 individuals to be entered on a single computer and then to analyze their health care stability over time and in relation to each other.

Starting in the late 90s several state DD Divisions began implementing and mandating use of the Health Risk Screening Tool to monitor the health and safety of individuals, and to determine the type and extent of professional support and training. States included: Tennessee, Louisiana, New Mexico, Maryland, Illinois and Georgia.

The web-based HRST began development in 2005 and was introduced in Georgia by the Department of Behavioral Health and Developmental Disabilities (DBHDD) in 2007. Previous to this, Georgia DBHDD had some 10,000 consumers on the paper HRST, but found the utility of the paper tool limited. From 2007-2015 some 15,000 consumers were entered into the HRST Online and is now updated annually, allowing the state the ability to monitor health status of individual consumers by region, by case manager, by provider or other individual entity.

Currently the HRST is utilized by Intellectual and Developmental Disabilities and Behavioral Health Divisions in nine states and over 2,000 private provider agencies in the United States.

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