Comprehensive care management and delivery for individuals with intellectual disabilities and chronic health conditions

Presentation will provide an overview of the health challenges faced in the population of adults with intellectual disabilities living in Rhode Island. We will discuss access to and barriers to preventative healthcare and present perspective from stakeholders including individuals with I/DD and community caregivers. An innovative program designed to improve patient activation, promote health and decrease duplicative or unnecessary emergency care will be presented. An interdisciplinary care management team model and processes will be described and implementation successes and challenges will be highlighted. Services provided, including non-traditional health care interventions such as mobility and gait evaluation, pharmacist led medication reconciliation and speech therapy, will be described. Particular attention will be directed to discussion of the benefits of community health workers including peer mentors and life coaches. The role of these workers in health education and promotion including community safety, relaxation techniques, nutrition, disease specific strategies, and medication management will be presented. Challenges to coordinating healthcare and social supports amongst diverse community providers will be identified. Strategies to mitigating barriers, such as the use of telemedicine and telehealth will be highlighted. Lastly, we will discuss interventions to address the social determinants of health specific to this population and offer examples of supports towards community inclusion, optimal employment, enhanced social supports, access to transportation, and self-advocacy.