Writing on the Wall: Spring 2022

Better Care Through Communication
Since 2020, our nursing team has
been involved with a project to improve
hospital care for people with
developmental disabilities in partnership
with Augusta Health hospital in
Fishersville, VA. A local coalition of
six agencies who serve this population
was formed to do a comprehensive
assessment of needs and collaborate
with the hospital for better care
and communication. I had the opportunity
to meet the MD leader of the
Vulnerable Populations Committee of
Augusta Health at a COVID vaccine
clinic and introduced the coalition’s
concerns. He immediately responded
positively and assured he would pave
the way for contacts in the hospital.
The collaboration was born!
The DBHDS/Office of
Integrated Health (OIH)
Registered Nurse Care
Consultants team was asked
for their support with the
hospital project. We discussed
how their office
plans to better support providers to
advocate for the best care and clinical
outcomes for the people we all
serve within the current broken health
system. All recognize that regulations
often do not match the reality of the
difficulties providers face when trying
to get proper care and treatment.
OIH had already begun the process of
considering supports, so the Augusta
Health project fueled their intentions!
The OIH team, local coalition, and
Augusta Health staff began working
together to develop meaningful dialog
and determine the first best steps to
meet the most significant needs.Our
meetings brought to light the hospital
staff’s desire to provide the best care,
but that many had not been trained in
medical or nursing school curricula to
provide care to this population. They
were eager to improve their knowledge
and be more aware of an individual’s
true needs.
The outcome of this group exploration
work is a set of advocacy documents,
which also serve as teaching
tools to start the journey to improved
care. Deanna Rennon, Wall Residences
QA Director, and I, Lead RN Care
Manager, had the privilege to join
with experts from OIH and the hospital
MD to develop:
• My Care Passport
• Consent Tip Sheet
• Medicaid Waiver Tip Sheet
• Discharge Tip Sheet
For more information about My Care Passport
and the Tip Sheets, please contact Kevyn Burn,
Lead RN Care Manager at 540-250-7832
or kburn@wallresidences.com.
My Care Passport is the central document.
Designed to be easy for the
Provider to fill out, it describes the
needs of the individual for medical
staff in an easy to reference format. It
covers who they need at bedside, who
can speak for them, feeding needs,
how they show pain, what comforts
them, and more. At Augusta Health
it is now posted at bedside and part
of the record. It is encouraged that it
be shared widely with all health care
providers caring for the individual.
The Consent Tip Sheet was specifically
requested by hospital medical staff
so they could know clearly who could
give consent, with whom they can
discuss care, and who they need to
listen to... the Provider, of course!
The Discharge Tip Sheet clearly tells
hospital medical staff what DBHDS
requires at discharge. It is an attempt
to solve the problem of Providers
trying to describe what is needed and
being challenged about the validity of
their requests by equipping them with
a document that shows, “DBHDS
says so!”
The Medicaid Waiver Tip Sheet gives
a short explanation of what the waiver
is and how it impacts the individuals.
Likely it will mostly be used with
Social Workers or Discharge Planners
and Case Managers to assist understanding
the support needs and how
those needs are funded.
The pilot at Augusta Health
began in January 2022 after
training the medical and nursing
staff on the new documents. The
grand plan includes assessing
the effectiveness of the pilot at
Augusta Health, then utilizing
the assistance of our Augusta
Health MD colleague to encourage
other hospitals to adopt these tools.
The four documents are now being
distributed, talked up, trained on, and
utilized throughout the State. The
OIH February Health Alert is about
the documents. Trainings are available
through our agency, the OIH site,
and other coalition agencies.
We request you obtain and use the
documents far and wide to teach our
health care providers about the needs
of people with developmental disabilities
and the systems that serve them.
Together, we can advocate for improved
care outcomes for the individuals
we serve.
~Kevyn Burn
5