CLASS Inc. (formerly the Citizens’ League for Adult Special Services) was created in 1976 by parents and community members to provide a day activity and training center for adults with developmental disabilities. CLASS Inc. provides day habilitation services, career/employment services, clinical support, production services, case management, advocacy, transportation, and assistive technology to the 300 adults enrolled in the program. CLASS Inc. currently has two sites – one in Lawrence, Mass. and one in North Reading, Mass.

I began working with adults with developmental disabilities in 1982. I worked at a state institution, in a sheltered workshop, and in a group home. When I began working at CLASS in 1999, I was a licensed practical nurse and later became a registered nurse. In 2001, I was promoted to the Health Services Coordinator and became certified in developmental disabilities nursing. In 2008, I was promoted to the Director of Health and Clinical Services. In this position, I am responsible for planning, delivering, and evaluating nursing and clinical support services for the individuals who receive services at CLASS, Inc.

Most of the individuals who attend the day habilitation program have multiple nursing, medical, and behavioral conditions with physical and cognitive impairments. These individuals have a vast range of diagnoses, including mental retardation, Down syndrome, Alzheimer’s disease, autism, cerebral palsy, seizure disorders, numerous genetic syndromes, and secondary psychiatric diagnoses, such as obsessive-compulsive disorder, post-traumatic stress disorder, and depression.

The nurses at CLASS are skilled professionals who are sensitive to the differences and the unique needs of individuals with developmental disabilities. The nurses must have good clinical and assessment skills and be prepared to intervene for both medical and psychiatric crises. The nurses must be knowledgeable about a variety of genetic disorders and anomalies that are not commonly seen in other settings. Registered nurses work full-time at both sites, and there is a licensed practical nurse in Lawrence. CLASS is fortunate to employ three registered nurses who have each been practicing nursing for more than 20 years.
 

The nurses interact with and observe the individuals on a daily basis. This interaction gains the trust of the individuals and makes it easier to gain the individual’s cooperation when the individual is ill, injured, or having a behavioral issue. Often, the individuals are fearful or resistant to nursing procedures due to past experiences.

It is important to know the individuals’ baseline level of functioning to enable the nurses to identify early changes in their health status that may be the beginning of a major illness. Nursing assessment skills are essential to maintaining optimal level of health and functioning in adults with developmental disabilities. The nurses observe for subtle and significant changes in behavior or abilities, such as withdrawal, drowsiness, signs of aggression, self-abuse, changes in appetite, or even behavioral differences. When an individual acts differently than usual, the nurses always attempt to rule out medical causes and talk with the person to determine what has changed.

Adults with developmental disabilities develop many of the same health problems as the general population – including diabetes, endocrine conditions, respiratory conditions, cardiac conditions, GI conditions, renal conditions, urological conditions – but they also develop unique medical problems due to their congenital or acquired conditions and the medications they take to treat these conditions.

The registered nurses complete comprehensive monthly progress notes and annual nursing assessments on all day habilitation participants. The nurses also administer medications, evaluate individuals for illness and injury, provide treatments, conduct trainings with the individuals and the staff, and maintain ongoing contact with the families, guardians, residential providers, and funding sources. The nurses submit an MD Update form to the primary care physician whenever a change in medical status is observed.

The day habilitation program provides assistance with communication, eating, hygiene, ambulation, mobility, sensory integration, fine motor skills, gross motor skills, money management, and community safety skills. This assistance allows the individuals to become as independent as possible at program and at home.

The clinical team includes a licensed occupational therapist (with 47 years’ experience), a registered physical therapist (with 27 years’ experience), a licensed speech therapist (with 23 years’ experience) and two certified occupational therapy assistants (COTAs). Each of the therapists work one to two days per week in a consultant capacity.

The therapists complete evaluations/assessments upon an individual’s admission into the program, every three to five years (per Medicaid regulations) and whenever an individual has a change in their level of functioning. The therapists make recommendations for the individuals’ annual Individualized Service Plan (ISP) goals. The therapists monitor the individuals’ progress by signing off on the quarterly ISP progress notes.

The nurses, clinicians, and program managers meet once per month to discuss progress on current projects and to brainstorm about upcoming changes. During the past year, the therapists have begun working with individuals on a Vestibular system, a stander, and the Nintendo® Wii. The COTAs facilitate specialized groups with the individuals.

Education is a primary focus at CLASS Inc. Individuals and staff receive annual training in first aid, OSHA, HIV/AIDS, and basic health-related topics, such as influenza and routine hand-washing. In addition, staff receives training in transfers, dining, occupational therapy, CPR, AED, seizures, vagal nerve stimulator, and proactive alternatives for change (self-defense), as well as medication administration for unlicensed personnel.

The content of the training materials and the delivery approach must be appropriate to the developmental level of the person. Repetition of the content is often necessary to ensure understanding of the material. It is difficult to assess the individuals’ grasp of the material if they are nonverbal, do not make eye contact, or ask questions for clarification.
 

The Safety Committee at CLASS is comprised of at least one individual from each department, the health and safety officers, and the nurses. Each department also has a staff person assigned as the health and safety officer. The committee meets monthly and all accident and injury reports from the previous month are reviewed. All participants contribute at least one recommendation to ensure the safety of the individuals and staff while they are at program. These individuals also receive human rights training monthly and each month has an assigned “Right of the Month.”

Individuals attend community trips to the Greater Lawrence Family Health Center for health and exercise classes, the YMCA, the Essex Art Center, restaurants, stores, local sites of interest, and volunteer sites. Participants enjoy classes in reality orientation, current events, sign language, arts and crafts, cooking, men’s group, women’s group, gross motor, and other subjects of interest.

In 2005, a wellness and exercise program was developed and initiated in collaboration with the Massachusetts-based Greater Lawrence Family Health Center. Two groups of individuals visit the health center weekly and receive educational instruction (weight loss, healthy eating) from Jeff Geller, MD, and participate in an exercise activity. The program was originally funded for one year by a grant from Massachusetts Department of Public Health, but the program was such a success, it has continued.

The individuals participate in several of the committees at CLASS, Inc. These committees include the Tour and Interview Committee, the Safety Committee, the Human Rights Committee, the Advisory Committee, and Social Group Advocates Standing Strong. Each department elects a president every two years and the president represents and discusses their department’s concerns at the monthly luncheon with the president/CEO of CLASS.

During the past 20 years, there has been a major shift from institutionalization to community living for individuals with developmental disabilities. Most of the individuals live in the community now, and many are receiving healthcare from primary care physicians who may need education about developmental disabilities and the impact of those disabilities on the individual’s ability to identify and communicate healthcare concerns.

In 2003, the Massachusetts Department of Mental Retardation developed and mailed the “Health Care Initiatives” to all primary care physicians who treat individuals with developmental disabilities. The guidelines shared some tips and alerted them to the published professional guidelines for healthcare of individuals with disabilities (such as health screenings and testing of individuals with Down syndrome). Some of the individuals who attend the program live with family members, others live in group homes for people with developmental disabilities, in adult foster care settings, shared living homes, or in nursing homes.

In 2001, CLASS created The Arc of Greater Lawrence, a consumer and family organization that offers expanded services to younger individuals with disabilities and their families in Lawrence and surrounding towns. Family forums are held twice per year, and they provide education on a wide variety of health-related issues. Most of the families are very open and very involved with the individual who is developmentally disabled.

CLASS also offers clinical experience for occupational therapy assistant students from North Shore Community College and high school students from Lawrence Vocational Technical High School. The students visit CLASS and receive exposure to the individuals in a familiar environment.

Care of adults with disabilities is both a career and a passion. It is challenging. There is always something different, and you have to always be alert and observant. It is a rewarding experience to work with individuals who are so grateful for everything that you do for them.

— Lisa Accardi, RN, CDDN, is the director of health and clinical services at CLASS Inc. in Lawrence, Mass. Questions and comments can be directed to editorial@therapytimes.com.