Behavioural Supports OntarioBSO Impact in Ontario and the CE LHIN

Presented by:Joy L. Husak – BSO Design Team

July 24, 2013

BSO Project Background

• BSO project is a $40 million Ontario wide project

in partnership with:• All Ontario Local Health Integration Networks(LHINS)

• Alzheimer Society of Ontario

• Health Quality Ontario

• Ministry of Health and Long Term Care

• Central East LHIN is one of 4 early Adopter LHINS

• $1.6 million investment in 2011/2012• $ 4.06 million on an annual basis

2

Overview - Purpose and Target Population• Behavioural Supports Ontario (BSO) Project was created:

To enhance services for older people with complex behaviours wherever they live - at home, in long-term care or elsewhere

To develop and implement new models of care that focus on quality of care and quality of life

To promote new ways to manage behaviours To provide standardized, consistent levels of care

• BSO population: older people with responsive behaviours linked to cognitive impairments, people at risk of the same and their caregivers; providing them with the right care at the right time and in the right place.

3

Composition of the Integrated Care Team1. Acute and Tertiary Care Team: includes psycho-geriatricians, behavioural nurses,

Occupational Therapists, Physical Therapists and Behaviour Therapists.

• outreach to long-term care • in-hospital care when required

2. NPSTAT (Nurse Practitioner Outreach Team):

• timely response to LTC to conduct advanced medical assessments for residents with escalated behaviours and medical care as appropriate

3. LTCH Behavioural support nurses and Personal Support Workers (PSW):

• Hands-on care - allowing evening and weekend coverage (when possible)• Participate in and lead quality improvement activities • Lead knowledge exchange activities within LTC and across CE LHIN

4. Psycho-geriatric resource consultants (PRC):

• expert input to quality improvement activities• develop improved processes of care • provide staff education.

4

Overview - BSO Framework• Pillar 1 – System Coordination

and Management

• Pillar 2 – Integrated Service Delivery: Intersectoral and Interdisciplinary

• Pillar 3 – Knowledgeable care team and capacity building

5

BSO Provincial Update•LHINs are moving from implementation to sustainability

Sustainability Plans posted on all LHIN websites

•Evidence that BSO is making a difference is accumulating 14516 people received comprehensive behaviours training 59381 clients supported by BSO trained resources 7018 clients assessed using common assessment toolkits 601 tests of change (PDSAs) and service improvements

•BSO is providing better care, better health and better value

• Alzheimer Knowledge Exchange continues to provide the structure for support and communications

6

BSO in Central East - Strategy• Phased - start with LTC and then move to Community

1. LTCH Stream

2. Community Stream

• Integrated Care Team to leverage current resources and expertise:

1. LTC Team – LTC staff and physicians; Psycho-Geriatric Resource Consultants (PRCs); NPSTAT (nurse practitioner led outreach to LTC); Geriatric Mental Health Outreach Teams (GMHOT), acute/tertiary care hospitals

2. Community Team – CCAC, Community Support Services; Primary Care, PRCs; GAIN (Geriatric Assessment and Implementation Network); Geriatric Mental Health Outreach Teams (GMHOT), acute/tertiary care hospitals

7

BSO in Central East – Quality ImprovementQuality Improvement philosophy: using small tests of change … Focus Learn Spread Sustain

Benefits of Quality Improvement Approach: • client-focused• ensures stakeholder understanding• creates ‘buy-in’ • excellent vehicle for knowledge exchange• provides value for money• focused on quality of care and improved outcomes• guaranteed to work

8

BSO in Central East – Quality Improvement

• Developed multi-stakeholder value stream maps (VSM) for each of the five client streams

Long-Term Care

I. Support provided by LTCH staff

II. Integrated Care Team

support

Community III. Prevention

and Early Stage Support

IV. Support from time of

LTC application

Acute and Tertiary Care

V. Transition to acute care, tertiary and specialized care

Focus Learn 9

BSO in Central East – Capacity Building for LTCHs, Community Providers & Integrated Care Teams

CE LHIN training February 2012 to March 2013Course Participants

PIECES 416

UFirst 328

Montessori 542

Gentle Persuasive Approaches (Train the trainer)

44

Sub-total 1330

Quality Improvement Facilitation Training (124 - 1 day, 65- 3 day training)

190

Total 1520

Learn 10

BSO in Central East – LTCCommitment of LTC Early Adopter BSO Teams

1. Enhanced care for people living with behaviours (including evening hours)

2. Participation and leadership in quality improvement activities 266 Plan-Do-Study-Act cycles completed

3. Knowledge transfer and spread to Phase 2 homes• Implementation Tables• Outreach visits with buddy homes• “Whatever is needed” to help Phase 2 homes implement BSO• Community of Practice events

Spread Sustain11

BSO 13 Early Adopter LTC Homes (2012)• Durham

• Wynfield LTC• Ballycliffe Lodge• Community Nursing Home Pickering

• North East

• Fairhaven• Riverview Manor• Caressant Care McLaughlin• Victoria Manor Home for the Aged• Streamway Villa, Cobourg

• Scarborough

• Shepherd Village• Yee Hong Centre for Geriatric Care- Finch• Trilogy LTC Residence• Bendale Acres• Seven Oaks LTC

12

BSO Phase 2 Homes (April 2013)

• Durham

• Hillsdale Estates

• North East

• St Joseph’s at Fleming• Community Nursing Home Warkworth • Lakefield Extendicare

• Scarborough

• Tendercare Living Centre

13

BSO Measures for Success

• Reduced resident transfers from LTC to acute or specialized unit for behaviours

• Delayed need for more intensive services, reducing admissions and risk of ALC

• Reduced length of stay for persons in hospital who can be discharged to a Long Term Care Home with enhanced behavioural resources

Learn 14

BSO in Central East - Highlights from EA LTC Metrics 2012-2013

• EA LTCHs have identified 1491 residents with a new or escalated behaviour through 2012/2013.

• 886 Behavioral Assessments Tools (BAT) completed. Overall, a BAT has been completed for 59% of those residents with a new or escalated behaviour.

• 905 residents received a change in treatment

• 869 residents received support from IC Team

• 50 transfers to ED for primary reason of responsive behaviours; this equals only 2% of population in CE LHIN EA Homes

Learn 15

BSO in Central East – Early SuccessesImpact:

• 886 residents assessed and served in 13 Early Adopter LTC homes in 2012-2013 • 1520 staff trained (2610 training days) • Behavioural Assessment Tool, Whiteboard, Client Care Process Flow utilized in

72% of Central East LTCHs• Community – draft design of Client Care Process Flow developed

Client Stories:

• Decrease of behavioural incidents in clients with responsive behaviours• Increased client cooperation with activities of daily care • Decrease in use of physical and pharmacological restraints to control behaviours• Admission of people with difficult behaviours from tertiary care settings and

behavioural support units

16

17

Lessons Learned/Observations• Common tools, common training = common language for

collaborative problem solving

• Standard process and tools increase communication & collaboration (require OTN sessions – training)

• Defined Value Stream Process provides a context to utilize new knowledge

• Visual process maps make it easy to learn the new process

• Staff initiate interventions before behaviours escalate

18

Next Steps…• LTC Stream

• Sustain gains in EA homes• Implementation Table teams will continue to provide leadership to spread BSO to

all Central East LHIN LTCHs • Refinement of GMHOT engagement processes• Metrics collection and analysis for all CE LHIN LTCHs

• Community Stream• Refinement of process, conducting small tests of change – PDSAs

• Other Areas of Focus:• Refinement of transfer process to and from hospital for LTC and Community

streams• Identify new leaders• Recruit and refresh membership of BSO Design Team and Evaluation Committee• Align with development and implementation of Regional Specialized Geriatric

Service Entity

19

The Need for Change…• More and more people are at risk for responsive behaviours

• Challenges are experienced across all health sectors and services

• The patient and family require better quality experiences

• There are significant costs associated with managing behaviours

• Recognized best practices could be adopted more systematically

• There is an opportunity to leverage existing initiatives in Ontario

• Stakeholders are ready for change

20

OTN AS A RESOURCE

• Collaborative events and In-services for all staff pertaining to delirium, person centred approach, healthy aging of people with developmental disability, palliative, mentoring and coaching

• Share knowledge and skills between all health and business sectors (build relationships) including physicians, mental health, paramedics, ambulance, emergency room staff, police, fire department, etc.

• Assessments (telemedicine), enhance delivery of service, and follow up

21

OTN AS A RESOURCE• Transfer of knowledge to post-secondary education

students to implement the BSO program within their course curriculum and integrate with student placement (capacity building)(hours for community service Co-op Students)

• Establish and expand OTN and teleconference availability (LTC/community); integrate family/SDM/POA for resident focused care

• Educate community, family members, residents, clients – proactive rather than reactive

22

OTN AS A RESOURCE

How can we help each other?

By bringing together diverse groups from traditional medicine, nursing, allied health professionals, academic institutions, technology and telecommunication organizations, e-health, physicians, hospitals, long term care homes, community agencies, government and others to overcome barriers to the advancement of telemedicine through the professional, ethical and equitable improvement in health care delivery.

23

OTN AS A RESOURCE

Benefits:

Widen our reach to individuals in a cost-effective manner

Convenient for clients, healthcare providers,family members, students, other business professionals

Increase in care, education, training with less travel

Satisfaction due to improved equipment and change in people’s perception of technology

24

For more information….• http://www.centraleastlhin.on.ca/report_display.aspx?id=21366

BSO page on CE LHIN website

• http://www.centraleastlhin.on.ca/page.aspx?id=23202 BSO hidden page on CE LHIN website

• http://www.akeresourcecentre.org/BSO Alzheimer Knowledge Exchange BSO webpage

• Joy L. Husak – Executive Director, Fairhaven – 705-743-0881, extension 231 – jhusak@fairhavenltc.com

25

26