Behavioural Supports Ontario

Quarterly Report | Q2 2012 / 13

Period July 1 - September 30, 2012

In partnership with:

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“The service from the Mobile Response Team has made all the difference. A coordinated, collaborative care plan, designed to support the client’s

specific needs, has been nothing short of phenomenal.”

Adele Pheiffer, RN Director of Care Belmont Long-term Care

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table of contents Message from the Project Sponsor .............................................. 4

Executive Summary ....................................................................... 5

BSO Overview

structure ..................................................................................................... 6

alignment .................................................................................................... 7 CRO activities and accomplishments ......................................................... 9

project level activities and accomplishments ................................... 9 new project supports ..................................................................... 10 LHIN action plans .......................................................................... 11 the Provincial Resource Team ....................................................... 11

knowledge exchange ..................................................................... 13 BSO evaluation update .................................................................. 15

Quantitative Outcomes

investment in HHR ................................................................................... 16 evidence of change | spotlight on QI data ................................................ 18

Qualitative Outcomes

quality improvement ................................................................................. 22

HQO coaching and leadership ....................................................... 22 BSO collaborative working groups ................................................. 24

capacity building ....................................................................................... 27

Introduction

Behavioural Supports Ontario (BSO) exists to enhance services for 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 (at home, in long-term care or elsewhere). Through development and implementation of new models designed to focus on quality of care and quality of life for this vulnerable population, a $40 million provincial BSO investment allows local health service providers (HSPs) to hire new staff-nurses, personal support workers and other health care providers, and to train them in the specialized skills necessary to provide quality care to these residents/clients.

Client-centered and caregiver-directed care where…

Everyone is treated with respect and accepted “as one is”

Person and caregiver/family/social supports are the driving partners in care decisions

Respect and trust characterize relationships between staff and clients and care providers.

Supporting principles bring these concepts to life for those making daily decisions about care:

Behaviour is communication

Diversity

Collaborative care

Safety

System coordination and integration

Accountability and sustainability

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the best is yet to come BSO is focused on lasting, sustainable cultural change. What does the future hold for BSO? We believe “we’ve only just begun!” We’ve accomplished a lot in a relatively short period of time. To date, more than 475 new front-line staff have been hired across the province, over 310 long-term care homes have increased their in-house behavioural supports and an estimated 14,000 new and existing front-line staff have received specialized training in techniques and approaches applicable to behavioural supports. Stories from every corner of the province reflect the positive outcomes of BSO and the project continues to showcase its leadership position by aligning with key provincial initiatives including Ontario’s Seniors Care Strategy. Q2 saw the emergence of quality data that supports the overarching principle of evidence-based care and practice. In the Mississauga-Halton LHIN there are two areas of note. Data analysis reveals a sustainable decrease in responsive behaviours of 98% in 4 Adult Day Programs as a result of BSO investments. Meanwhile, cost statistics confirm an extrapolated system savings in excess of $330 thousand dollars per annum with the infusion of only 4 Community Support Workers. Think of how such resources could be reinvested to enhance the excellent care taking place. BSO provides the right care and, in so doing, is improving client-outcomes and system value. I am also mindful of the stories peppered throughout, of how BSO is, as one BSO System Navigator has related, acting in the role of “Guardian Angel.” BSO trained health care professionals improve the care experience by making care more accessible; providing a smooth journey through the system by ensuring clear communication and strong engagement both among providers and between providers and care recipients. It has taken an incredible amount of work to get to this point but we know the best is yet to come! The challenge will be to apply the same commitment and effort as we press forward. We know the BSO target population – older people with responsive behaviours linked to cognitive impairments, people at risk of the same, and their caregivers – resides in a variety of locations including at home, in long-term care where so much of BSO’s success has occurred thus far, and elsewhere. It’s now time to do more of the same, especially for people at risk and their caregivers. Meanwhile, with the BSO pillars as our continued guide to service transformation and better care quality, the “best” of BSO will require more collaboration across all sectors of the health system, engagement of strategic partners and ongoing expansion into the community services sector. These are the areas of opportunity for the road ahead. From a project standpoint there is no turning back... no winding down... no stopping now; we have come too far in pursuit of lasting, sustainable and meaningful change.

Donna Cripps CEO, Hamilton Niagara Haldimand Brant

LHINBSO Project Sponsor

“It’s like being a Guardian Angel. I advocate for those who cope with

responsive behaviours, while guiding and watching over caregivers who are

on their respective journeys through an often complex, complicated and un-

coordinated system.”

Jillian Heard, BSO System Navigator Erie St. Clair LHIN

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executive summary

BSO continues to create a system of care across the Province and enhance services for older people with responsive behaviours linked to cognitive impairments, people at risk of the same, and their caregivers This report is built around three main sections - Project Overview, Quantitative outcomes and Qualitative outcomes, collectively providing a broad understanding of BSOs current state as at September 30, 2012. CRO continued to spread information, knowledge and awareness about the project through a variety of channels. The project also continued to play a leadership role by aligning itself with key provincial initiatives including Ontario’s Seniors Care Strategy. With an eye to the future, the CRO leadership team came together in September for a face-to-face planning session that sets the agenda for the project moving forward. LHINs have continued to successfully press forward with the implementation of their action plans and BSO is making a difference. Anecdotal stories from across the province are noted throughout the report, highlighting quality patient-centred care. Equally important is that data is beginning to show impacts on patient care and the healthcare system. “Spotlight on Data” demonstrates that BSO is providing better care, better health and better value. During Q2, LHINs continued to support local Health Service Providers to recruit the best possible BSO staff for this initiative. As of September 30, 2012, a total of 475 FTEs had been recruited province-wide, up from 392 FTEs reported at the end of June 2012. Supporting all aspects of the Project, BSO’s communities of practice and collaborative working groups have continued to work effectively. LHINs are testing and refining processes, and showing creativity and innovation along the way. Proven new tools, care pathways and approaches to clinical integration are emerging in large numbers, and the pace of change is accelerating.

Angels Among Us

The goal of the BSO System Navigators in the Erie St. Clair LHIN is to improve the care experience by making care more accessible; providing a smooth journey through the system by ensuring clear communication and strong engagement both among providers and between providers and care recipients. “It’s like being a Guardian Angel,” said Jillian Heard, BSO System Navigator. “I advocate for those who cope with responsive behaviours, while guiding and watching over caregivers who are on their respective journeys through an often complex, complicated and un-coordinated system.” Jillian recently advocated on behalf of a caregiver who felt quality of life was not taken into consideration for either her husband or family, when developing the care plan. Frustrated and unable to move forward with important client-centred decisions, Jillian brought together multiple service providers, including the Alzheimer Society, to collaboratively consult on the case, provided support to the caregiver and family, and educated all parties involved on possible interventions that would help with advanced responsive behaviours. “The patient was not transferred to another facility, which would have created a financial and transportation hardship for the caregiver and her family,” said Jillian. “Not only did the client need more time to adjust to medications, the caregiver and family needed more time to understand all of the options in order to make informed decisions. Collective decisions were made and most importantly, the client, his primary caregiver and family were treated with the dignity and respect they deserved.”

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structure

The North Simcoe Muskoka (NSM) LHIN is accountable to the MOHLTC for leading the Behavioural Supports Ontario (BSO) Project. In partnership with the Alzheimer Society of Ontario (ASO), Alzheimer Knowledge Exchange (AKE), and supported by Health Quality Ontario (HQO), project coordination and reporting is being led by the Coordinating and Reporting Office (CRO), NSM LHIN. CRO is responsible for the implementation and evaluation of the BSO Project, ensuring consultation, liaison and oversight throughout Phase 2 implementation. Committee structure includes...

Coordination and Reporting Office (CRO): this Advisory Committee has oversight on the BSO Project and authority to make project-level decisions.

Provincial Resource Team (PRT): a clinical resource and advisory body for the CRO.

Education & Training SubGroup: provides resources for the province and LHINs designed to implementation of BSO Action Plans; notably, capacity enhancement through learning, knowledge transfer and development programs.

Fourteen-LHIN Contact Group (formerly Early Adopter Steering Committee): a table for problem-solving and joint strategy among LHINs and the project’s funded partners – CRO, PRT, HQO and AKE.

Data, Measurement and Evaluation Committee (DMEC): provides strategic direction to the Impact Assessment (“Evaluation”) of the BSO Project’s implementation phase (August 2011 – December 2012). In addition, the DMEC provides subject matter expertise, strategic direction and recommendations regarding project evaluation to the Contact Group.

BSO overview

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Communications and Knowledge Exchange Working Group: provides subject matter expertise, strategic direction and recommendations to Contact Group and the CRO on all matters related to communications and knowledge exchange.

Long-Term Care Provider Advisory Council: a monthly forum for

representatives of the Ontario Long-Term Care Association (OLTCA),

Ontario Association of Non-profit Homes and Services for Seniors

(OANHSS), Ontario Long-Term Care Physicians (OLTCP), the Ontario

Association of Community Care Access Centres (OACCAC) and the

CRO. Members collaborate with BSO on matters related to long-term care

homes (LTCHs) and CCACs with the goal of improving support to the

BSO population.

alignment

BSO aligns with the current direction and priorities of our Provincial Government. The project is focused on providing the right care at the right time and in the right place. The BSO Framework supports a wide range of recommendations brought forward in recent research and reports seeking better care, better health and better value. Key alignments include… Ontario’s Action Plan includes the following priorities: keeping Ontario

healthy, faster access, stronger link to family health care and right care - right time - right place.

The Provincial Budget allocates resources to meet the needs of the population living with complex and chronic health conditions (the 1% of the population that currently takes 34% of Ontario’s health care budget) The target population of BSO is the population identified in the 1% - those living with health challenges, including cognitive, functional and mental illness.

The Drummond Report makes recommendations for those individuals living with complex and chronic health conditions.

The Institute for Healthcare Improvement (IHI) Triple Aim Framework keeps the focus centred on the population’s care needs while working together to achieve better health, better care, better value for the health system supporting this population.

Report of the Long-Term Care Task Force on Resident Care and

Safety called for enhanced staff training in responsive behaviours that

aligns with the BSO program in Recommendation 8. In addition, BSO

directly addresses Recommendations 6 (Develop strong skilled managers

and administrators), 13 (Direct-care staffing in Homes) and 14 (Support

residents with specialized needs).

Chili and a Shake In a recent survey of long-term care home directors across the Champlain LHIN, 71% of respondents indicated they saw improvements in the quality of life for residents, and 60% said they saw improvements in job satisfaction for staff as a result of the Behavioural Support Champion (Champion(s)). Champions are located in each long-term care home within the Champlain LHIN. Working hand-in-hand with the behavioural support outreach nurses that visit the homes, care plans are developed for residents with challenging, responsive behaviours. When the outreach nurse leaves, the Champion remains with the resident to help execute the plan. Champions are providing 26,000 hours of personal care across 61 long term care homes in the Champlain LHIN. A resident with dementia arrived into a LTC home refusing to eat or bathe and the situation was discussed in detail at a cross-functional meeting designed to meet the complex needs of specific residents. Effective knowledge sharing and transfer resulted in a number of changes being made for the resident including placing him at a table in the dining room where there was staff support and fewer distractions, and providing different types of foods to see what was most palatable; a chili sandwich made all the difference. Giving him a handshake at the start of any interaction reassured him that he was in a friendly environment. To lessen anxiety they mapped out a bathing routine and set up a two-hour toileting routine to avoid incontinence. “Certainly, what they’re doing is working,” said the residents wife. “I see the difference. Before, he would shout and yell and hit the wall and now, he is happy and content. That’s what means the most to me… that is what pleases me… he has settled in.”

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Dr. David Walker and Professor G. Ross Baker’s Reports (2011) recommending system redesign to meet this population’s needs. Notably, BSO is committed to improving the capacity for older adults to live independently and reduce readmission rates; thereby resulting in a better care experience for older adults and their families.

“Cross-System Responsiveness to Special Needs Populations - The ministry should support creation of special units/programs in the community and LTC homes for seniors with special needs. Targeted investments should focus on adding new human resources specialized in responsive and challenging behaviours in LTC homes, developing and deploying mobile behaviour teams, and expanding services in the community.” - Walker (2011) / Caring for Our Aging Population

Dr. Samir Sinha’s Seniors Care Strategy Report (expected 2012) is in the consultation phase with multiple stakeholders across

the province. His report will describe steps to ensure Ontarians aged 65 and older stay healthy, live at home longer and receive

the right care, at the right time and in the right place.

BSO’s target population is integral to a comprehensive seniors’ care strategy for Ontario. As an enabler, BSO already provides

many evidence-based solutions.

At the heart of BSO success is the unwavering desire and commitment to create a system that ensures people are treated with

dignity and respect, in an environment that supports safety for all and is based on high quality and evidence-based care and

practices. The interventions earlier in older people's 'health journey' are critical to assuring long-term improvement in their health

and ability to cope.

In addition to enhancing care for older adults with or at risk of responsive behaviours and their caregivers, BSO catalyzes change

that supports and is integrated with LHIN and provincial government priorities for seniors. It uses the tools and techniques of

quality improvement and knowledge exchange sciences to support evidence-based transformation of the healthcare system.

Score one for Mr. Harvey When “Mr. Harvey”, a resident with frontal temporal dementia, demonstrated exit seeking behaviors continuously throughout the day, evening and night, the staff at a Waterloo Wellington LHIN long-term care home were at odds with what to do. Mr. Harvey resisted all forms of care and demonstrated agitated behaviors such as removing screens from windows, smashing windows with stools and physically hitting and yelling at staff. He was not sleeping well and often awoke easily during the night restlessly, pacing the halls. So what to do with a resident who was a very active man (loved hockey) prior to his admission, and who prided himself on a strong work ethic? You distract and divert by placing some routine and rigor around his day using his interests as the focal point. Mr. Harvey soon began to help the maintenance and housekeeping staff, take walks outside with the recreation and restorative team, socialize with fellow residents during tea time, engage with staff in conversations about hockey (magazines, video, television – it was all about hockey!) and collaborated with his family to plan their visits. Mr. Harvey was indeed distracted from his negative behaviour but, unbeknownst to him, he had become an active participant in his own care plan. “Creating diversions… the ability to distract from the negative behaviour, to make work of idle hands and to fulfill minds, seems like such a simple yet overlooked answer, “said Jill MacQueen, RN, Special Care Unit. “Who would have thought? I can’t believe we didn’t do this sooner!” Mr. Harvey has since demonstrated a marked decrease in the number of agitated behaviors. And, although he still requests to go home to see his family, the active exit seeking behaviors have virtually disappeared. “Relationships are largely based on trust” continued Jill. “Perhaps what impresses me the most is that instead of distrusting staff, and his fellow residents, Mr. Harvey now likes to be with all of us as much as possible. Staff even

document in the lounge now so that he can sit with us and chat… about hockey.”

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coordination and reporting office

project-level activities and accomplishments

July 30 BSO event for Psychogeriatric Resource Consultants and Geriatric Mental Health Outreach teams in Toronto. 14 LHINs represented.

July 31 An estimated 160 CCAC case managers, Purchased

Service Agencies and Service Workers joined an online dialogue about extending the project to better reach community-based clients.

August 21-30 NSM, CW and MH LHINs sent almost 200 front-line staff

for training in quality improvement techniques at Residents First and BSO combined training events. NSM participants completed a BSO “rapid change” kaizen event, while staff from MH and CW applied their new training to real-life case studies from their local BSO projects.

August 30 Memo to BSO stakeholders announcing Bernie Blais’

departure to become CEO of Bruyere Continuing Care in Ottawa.

September 1 MOHLTC designated new Behavioural Support Units at

Baycrest and Cummer Lodge under the Long-Term Care Homes Act in Toronto Central and Central LHINs.

September 11 BSO briefing for Dr. Samir Sinha, Expert Lead for

Ontario’s Seniors Care Strategy. September 11 BSO leadership team, including chairs of all BSO

committees, met for a strategy session to discuss priorities and potential next steps for the provincial project.

September 19 BSO presentation to the Geriatric Emergency

Management annual conference. September 20 An estimated 200 health service providers and other

BSO stakeholders joined an overview webinar describing the BSO Evaluation.

September 21 BSO presentation to the joint national conference of the

Canadian Coalition for Seniors Mental Health and the Canadian Academy of Geriatric Psychiatry.

Take Five In collaboration with community support services, the North Simcoe Muskoka LHIN Behavioural Support System Mobile Support Team (BSS MST) has been able to increase respite support, help minimize the impact of caregiver stress and assist families to feel confident in their abilities to cope with responsive behaviours. When coping with responsive behaviours caregiver burnout is all too commonplace and such was the case with an NSM family who was experiencing increased agitation at home. To ease family stress by increasing respite care, integration with an adult day program was identified as a goal. Through collaboration with the NSM Community Care Access Centre (CCAC), the Victoria Order of Nurses (VON) adult day program and family, the MST was able to have a client successfully attend an adult day program. The MST Community Support Worker (CSW) observed the client in the home and spoke with the Personal Support Worker (PSW) who provides respite for strategies and interventions that are currently working in the home. The MST CSW was also able to help coach the family, providing them with strategies on how to present the day program to their family member, and how to build confidence in the family’s ability to respond to the behaviour. Outside of the home, the MST CSW worked with the coordinator of the adult day program toward seamless transition and shared valuable knowledge gained through observation and communication with the PSW to the rest of the MST. Of meaningful value, the MST CSW was also able attend the day program with the client on the first day, allowing for a warm transfer and assuring the family that their loved one was well supported. The client now attends the adult day program once a week, with plans to increase that frequency soon, and the five hours of increased respite the day program provides, allows the family to have a much needed break.

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new project supports

BSO spread in community – The July 31 “Spread to the Community” webinar continued a dialogue that began at the OACCAC

conference in June. Feedback received from the group has been used to develop the agenda for an all-LHIN event in Toronto in the

Fall, continuing to build the project’s momentum for community-based clients.

Communications strategy – A new consolidated Communications & Knowledge Exchange Plan integrates the provincial

communications plan approved last winter, the project’s combined web presence, and AKE knowledge exchange structures and tools.

The renewed Plan reflects input from AKE, the LTC Provider Associations, and LHIN representation. Local BSO Communication Plans

maintained by LHINs continue to link as they always have with the provincial BSO plan.

BSO Executive Sponsor – Former NSM LHIN CEO Bernie Blais handed BSO Executive Sponsor duties to Donna Cripps, CEO of

HNHB LHIN. Interim NSM CEO Jill Tettmann retains responsibility for various BSO accountabilities that belong specifically to her LHIN.

BSO funding, committees and the Coordination & Reporting Office are not affected by this change.

BSO collaboration with Residents First – The “Behaviours” change package of Residents First and BSO target the same objectives

in many of the same LTC homes. The two programs co-sponsored joint training sessions for front-line staff in August that applied

Quality Improvement science to implementation challenges from the BSO project. Central East, North West, Waterloo Wellington,

HNHB and possibly South East LHINs have scheduled dates in the fall with Health Quality Ontario to try the same approach with their

own teams.

BSO submission to Seniors Strategy – Throughout September the CRO profiled BSO, early impacts and cooperation opportunities

in conversation with Seniors Care Strategy Expert Lead Dr. Samir Sinha. CRO emphasized that BSO is a catalyst for change that fits

well with LHIN and provincial priorities, that measurement and targets will be key success factors for Dr. Sinha’s strategy, and that

existing BSO partnerships and momentum could be leverage during implementation of his final report.

In the six months prior to BSO involvement in HNHB LHIN, Mrs. S. accessed the hospital 12 times, and had no formal or informal supports at the time of referral.

With BSO involvement Mrs. S. has not accessed the hospital in over a month.

“I am so thankful for everything they have done for me. I have never had anyone help me this much before.”

- Mrs. S

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LHIN action plans

Final, CEO-signed Action Plans are available on LHIN websites or through

www.bsoproject.ca as follows:

Central

Central East

Central West

Champlain

Erie St. Clair

Hamilton Niagara Haldimand Brant

Mississauga Halton

provincial resource team (PRT)

Through Q2 the Provincial Resource Team (PRT) continued with their

mandate to surface promising practices, identify and address broad challenges

and connect LHINs to timely and relevant information so as to inform local

implementation. In addition, the PRT provided targeted project advice and

expanded its membership by adding representation from addiction services

and a large health care centre.

Surface Promising Practices: During Q2 the PRT aimed to surface local

promising practices, allowing LHINs to learn from and build on the success of

others. LHINs were invited to take part in “first-round exchanges” throughout

Q2; joining the PRT meeting for 30 minutes to present 1-2 promising practices

emerging in their respective areas. Building on the success of these first

round exchanges, including positive feedback from both LHINs and members

of the PRT, a second round of exchanges began in September. These

exchanges offer an opportunity for PRT members to respond to promising

practices, suggest additional considerations and recommend new partnerships

to explore.

Promising practices shared in Q2 included:

Developing local education and training programs and frameworks

Embedding Personal Support Worker (PSW) Champions to share skills

and coach other staff

Initiating cross-service Team Huddles to establish goals for the Mobile

Support Teams, bring forward potential behavioural approaches, and

collaboratively prioritize and implement these strategies.

Address Challenges: During each LHIN update to PRT, Leads were encouraged to bring forward any emerging issues that PRT may

be able to assist with. PRT members responded to these issues by taking into consideration the local contextual elements and

suggesting resources, processes or new partnerships for consideration. Throughout this process, PRT recognized that some

challenges were being identified by multiple LHINs and / or were large enough issues to required further provincial action. In these

cases, PRT facilitated subsequent action, exchange and response to address these challenges from a broader perspective.

Bridging the Cultural Divide Diagnosed with dementia, Mr. Singh’s family faced the difficult decision to place him in a LTC Home; a difficult decision for many, a hard transition for most and complicated when faced cultural considerations are in play. With his behaviours becoming increasingly difficult to manage, the LTC Home turned to their assigned BSO Psychogeriatric Resource Consultant (PRC) in the Central West LHIN for assistance prior to admission. “BSO focuses on the uniqueness of each individual situation and we take pride in our collective ability to work as a team for outcomes that provide the right patient-centred care plan,” said Cheryl Graham, PRC. “My knowledge is only enhanced by that of my colleagues, including Mandeep Bhullar, who brings her understanding of culture and diversity to the plan.” Cheryl, an expert in understanding dementia related behaviours, reached out to Mandeep, a diversity expert. Together they addressed the behavioural issues of Mr. Singh and “guilt factor” of the family for placing their loved outside the family home. They provided reassurance and support to both Mr. Singh and his family, and advocated on their behalf during a stressful transitional period. The family noted Mr. Singh had adjusted to the new environment and that his behaviour was calmer. However, they were sincerely thankful with the care and sensitivity given his cultural needs, allowing them to free themselves of the guilt that came from placing their loved one in a long term care home.

North East

North Simcoe Muskoka

North West

South East Part A | Part B

South West Part A | Part B

Toronto Central

Waterloo Wellington

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Complex Case Resolution:

One LHIN was having difficulty identifying and mobilizing appropriate supports for a very large individual with Pick’s disease and

multiple responsive behaviours. They brought the case forward to PRT, who identified that BSO clients are often complex and high

intensity- requiring multiple services and supports. The PRT explored how these complex clients are served when they don’t fit within

the current system structure. PRT has subsequently identified three (3) LHINs which currently mobilize processes for complex case

resolution in broader populations. These LHINs have been invited to a Q3 PRT discussion to share their approaches. Based on

previous knowledge and information shared in these examples, PRT members will develop a set of recommended components for

resolving complex responsive behavior cases.

Connect LHINs to Timely and Relevant Information: To build on the principal of knowledge exchange, which is embedded

throughout all levels of the BSO project, the PRT continues to provide a “PRT Update” e-news to LHIN leads following each meeting.

These updates connect LHINs to practical, timely and relevant information to inform implementation. Where other knowledge

dissemination processes in the project focus on broad project messaging, this publication targeted to considerations that can

immediately improve system coordination, service delivery and capacity building at the local level.

Episodic Project Advice: Throughout Q2 the PRT provided invaluable strategic direction and recommendations on BSO provincial

topics, including Messaging regarding the Seniors Care Strategy and BSO, Activity tracking processes, Mobile teams matrix

(developed by the Mobile Teams Collaborative) and the BSO Evaluation.

Fight or Flight “Sarah,” a long-term care home resident, exhibits a variety of outward behaviours associated with early onset Alzheimer’s. Prone to exit seeking, she had managed to elope from the locked unit three times in an eight-hour shift. A risk to herself and others, the result was one-on-one care. Sarah also wanted to prepare and serve herself meals in a facility ill-equipped for such activity and, as a result, meal times became a high risk period when she would often manipulate the locks on kitchen doors in an attempt to serve herself. Increased frequency of medication use had little effect on Sarah who simply became more agitated by staff that constantly wanted her to take her medications, sometimes 3 or 4 times per shift. The North East LHIN BSO team was asked to work on a care plan for Sarah and, following an initial assessment, several changes to her environment were made. A steel door with sophisticated locking system was installed for kitchen access and painted to look like a fence. Frosted glass was installed on all exit doors to impede views. A designated self-serve area was built into the dining room where Sarah and other residents could freely serve themselves, and staff was kept to a schedule that reduced opportunities for elopement. Sarah also received intense client-centred care. Having the BSO team already established in the long-term care facility allowed the team to focus on her needs immediately and, with BSO staff providing extra support and new activities - sorting laundry, putting clothes away and stacking shelves, the facility has been able to engage and monitor Sarah without requiring a staff member assigned only to her. Sarah’s medications have also been adjusted to better manage her behaviours. Sarah is no longer considered a high risk resident, her quality of life has improved and her family is very appreciative of the positive impact BSO staff have made.

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knowledge exchange

In support of BSO the Alzheimer Knowledge Exchange (AKE): Supports existing and newly hired health service providers to

develop core competencies and to refine and apply

practice models emerging from the BSO project

Identifiesand disseminates best practice concepts, tools and

resources

Provides Knowledge Transfer and Exchange (KTE) support toBSO

Collaboratives

Supports the spread of BSO in the community.

Throughout Q2, the following activities took place:

Support existing and newly hired health service providers to develop core competencies and to refine and apply practice models emerging from the BSO project.

Initiated BSO Capacity Building Community of Practice (CoP) meeting to support those involved in planning and implementing local and provincial BSO capacity building activities. The purpose of the CoP is to:

Create awareness of local BSO capacity building activities across the province Build on and adapt the work of others to meet local needs Collaborate to develop common resources, tools and new ways of seeing and doing things related to BSO Capacity Building Plan for sustainability of capacity building activity for continued high

performance among BSO care providers. Two online meetings providing opportunities to discuss Health Human

Resources self-assessment tools and the Person Centred Team Based Service Learning model were held during Q2. In addition a survey with members of the CoP about local capacity building activities was conducted.

Developed “The Road Ahead: Supporting Sustainable Capacity

Building” a tool to support individuals, teams or organizations in their continual development of the 12 BSO recommended Core Competencies. It describes a selection of strategies to support learning to enable decision-making about how, why and with whom they plan their continued capacity building.

On target for release in Q3, The Road Ahead complements the BSO Capacity Building Roadmap and is one of a suite of tools available to support capacity building. In order to provide better context about each of these tools and the relationships between them to illustrate how they can be used most effectively together, a document linking the The Road Ahead, Capacity Building Roadmap, BETSI and Person-Centred Team-Based Service Learning model is also in development.

High Quality Tools for Ongoing

Capacity Building

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Identify and disseminate best practice concepts, tools and resources. Planned and hosted 3 Knowledge Dissemination sessions:

The BETSI Tool (July 18) for enablers of education and training – Psychogeriatric Resource Consultants, Public Education

Coordinators, Mental Health, Addictions and Behavioural Issues community of practice members and CCAC educators. 85

people attended. 96% of those who completed a poll at the end of the session rated it as either very or somewhat useful and

72% said that they plan to apply what they learned to their work.

The Engaging Your Community (July 31) with Cathy Hecimovich and Brian Laundry for CCACs and community

organizations. 160 people attended this session.

BSO Interim Evaluation Results (September 20). 200 people attended this session.

Highlighted BSO updates in the AKE newsletter with a distribution of more than 3000. Collected and shared resources and tools on the BSO collaboration space and public BSO website. With the Communications and Knowledge Exchange Committee began planning for a process to facilitate the collection, storing

and sharing of tools, best practices, resources etc. among LHINs and others implementing BSO locally. Provide Knowledge Transfer and Exchange (KTE) support to BSO Collaboratives: Implemented Knowledge Broker support to the 3 active BSO Collaboratives (Mobile Response Teams, Centralized Intake and

Behavioural Support Units). Knowledge Broker support to the Mobile Teams Collaborative led to the development of a workplan

providing direction for the group. For the Centralized Intake Collaborative, this support has been provided through coaching in

meeting design and facilitation to foster dialogue and knowledge exchange.

Supported conversations with Waterloo Wellington and Hamilton Niagara Haldimand Brant LHINs regarding BSO related primary

care activity and the development of the Primary Care Collaborative.

Participated in e Primary Care Memory Clinic team Booster Day, including sharing information about the BSO project with participants.

Supporting People Living in the Community

In Q2 the project has increased attention to community-based clients of behavioural support services. AKE and CRO determined the following goals for this work: Support the needs of those experiencing responsive behaviours who live in the community

Build upon/strengthen existing resources and pathways

Facilitate broad community capacity building to foster supportive communities – everyone plays a role.

In response AKE has… Created a plan for fostering engagement with BSO in the Community Began plans for an in-person meeting and consultation with a variety of stakeholder groups on further

integration of BSO into the Community to be held in Toronto in Q3. The goals of this meeting include:

Involved participants in defining the desired future state for behavioural support for those

experiencing responsive behaviours who live in the community

Examined service needs, processes and gaps between the current and desired future state for this

population

Provide examples/illustrations of activities that respond to gaps and examine enablers of success

Identified methods, ways, resources for improving the system of care within BSO framework

Proposed a shared course of action and agree on next steps

Invited LHINs and community groups who are doing great work in the community related to BSO to

share this work with others through online Knowledge Dissemination sessions.

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BSO impact assessment | evaluation Second quarter 2012/13 activity of the BSO Data Management and Evaluation Committee (DMEC) has focused on refining indicators identified in the March report, measurement approaches as well as ensuring data availability for the final evaluation report. In addition, discussions regarding sustainable approaches to the collection and use of BSO metrics have begun. The DMEC has supported collaboration between the Hay Group Health Care Consulting team and the early adopter LHINs in an effort to promote a better understanding of the types of indicators and data already being collected at numerous levels (at the long-term care home level, at the community level and at the LHIN level) as BSO initiatives are implemented. This process has been facilitated by quarterly reports from the Health Quality Ontario (HQO) IFs at the DMEC meetings, as well as by provincial activity tracking methodologies that have been developed. This work will ensure that Hay Group has access to the best available information to support the indicators selected for the provincial evaluation, and will reduce duplication and data collection burden. Similar collaboration has occurred between Hay Group and Health Quality Ontario, to ensure any relevant QI indicators are incorporated, as appropriate, into the evolving evaluation framework. The DMEC has supported the development of the qualitative data collection methodology being used. User satisfaction and perception of impact of the BSO initiatives are being collected through surveys and focus groups. Evaluation timelines for the final report present methodological challenges for the qualitative data collection since implementation is in early stages. However, the qualitative approach will include rich information on “user experience” and ensure that early impacts are being noted. The LHINs have been key collaborators with this work, as the provincial evaluation will not only provide them with information that can be useful for QI purposes, but should inform the methodologies that they will implement for qualitative data collection within their LHIN on a longer term basis. The DMEC has continued to work to establish a BSO client filter for IntelliHealth. As a result of this work, IntelliHealth users will easily be able to identify the target BSO population and so evaluate impacts on acute care utilization in the future. The DMEC has also been working to define the approach that Hay Group will use for specific parts of the evaluation, such as the economic analysis, to ensure provincial expectations are met. The DMEC is promoting access to the administrative data required for the quantitative portion of the evaluation. Requests for 2011/12 and 2102/13 YTD inpatient (DAD) and ED (NACRS), long-term care (CCRS), rehabilitation (NRS), and mental health (OMHRS) data have been made on behalf of the consultants by the NSM LHIN. DMEC is considering ways to mitigate the impacts of delays in provincial reporting timelines for 2012/13 CCRS data, which will likely result in a lack of data availability in time for analysis and reporting timelines for the final evaluation.

The Caregiver Perspective Courtesy Sean Weylie, Mississauga Halton LHIN

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Both Qualitative and Quantitative outcomes are important to BSO for distinct reasons. Quantitative outcomes, such as those provided in Section 2 of this report, provide statistical and/or numerical understanding of where the project is positioned against a variety of its targets/deliverables i.e., patient impacts, HHR recruitment and the training of both new and existing staff. The information that follows paints a numerical picture of BSO.

investment in HHR

The MOHLTCs $40.37M Provincial BSO investment has focused on the hiring, by local Health Service Providers (primarily long-term care homes), of new staff – Nurses, Personal Support Workers and other health professionals, and the training of both new and existing staff in the specialized skills necessary to provide quality care to Ontarians with complex behaviours. Each LHIN’s Action Plan outlined a local implementation approach to deploy a range of specialized behavioural supports across the care continuum. There were three general approaches that emerged: Lead/host LTC Home Model for Mobile Outreach Teams Allocation at the individual LTC Home level Specialized Behavioural Support Units While approaches vary depending on geography and existing resources, the overall objectives are the same - maximize services for persons with challenging and complex behaviours associated with dementia, mental illness and other neurological disorders. These approaches were detailed in the quarterly report submitted to the ministry April 30, 2011- (see Behavioural Supports Ontario Q4-Quarterly Report January 1,2012 – March 31,2012. Section 2.3 HHR Investment pp 20 – 29). As of September 30, 2012, a total of 475 FTEs had been recruited province-wide, up from 392 FTEs reported at the end of June 2012 for the previous Quarterly Report.

quantitative

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What’s Up at Buttercup? “Mrs. Smith” is an 86 year old widowed woman who currently resides at Buttercup Retirement Residence and has been diagnosed with mixed dementia. Referral to the South West LHIN Behavioural Support System (BSS) team was made by Mrs. Smith’s geriatrician, as Mrs. Smith had displayed increasing resistance and verbal aggression toward staff when attempts at cueing for care occurred. The team’s Social Work and Occupational Therapist Case Managers performed a psychogeriatric assessment on Mrs. Smith, while a Social Worker and Occupational Therapist were assigned to perform a thorough psychosocial assessment, including assessment of the client’s ability to perform the ADL’s. The retirement residence manager created new care plans for Mrs. Smith based on recommendations that stemmed for the team’s findings. Involvement of BSS has allowed Mrs. Smith to maintaining her quality of life in the retirement home setting, thereby delaying her placement into a long-term care facility. It has also vicariously provided some validation/education for certain retirement home staff members. The retirement residence manager acknowledged and thanked the BSS Case Managers for the interactions with staff; she stated that it created a team-building dialogue for the retirement staff members who work with this particular client.

The Great Differentiator At Belmont Long-Term Care in the South East LHIN, the BSO Mobile Response Team has been working in partnership with staff to reduce the frequency of Responsive Behaviors for “Mrs. Lawrence,” and to identify the key times when one-on-one care is essential in order to reduce her emotional distress. “Mrs. Lawrence was calling out constantly, demonstrating socially inappropriate behavior through repetitive physical movements and restlessness, she complained repetitively and, due to her dementia, demonstrated varying levels of cognitive function,” said Adele Pheiffer, RN Director of Care at Belmont. “The service from the MRT has made all the difference and has been nothing short of phenomenal in supporting her specific needs through a coordinated, collaborative care plan.” The cross-functional team was able to collectively review Mrs. Lawrence’s behaviours, identify when they were happening and aid staff in identifying intervention strategies to reduce the frequency of outbursts, the escalation of same and identify the key times when they were happening. Calling out has lessened and there are fewer outbursts by co-residents who had been yelling at her to stop her behavior; which means for these residents their distress has been decreased. Notably, resident safety has prevailed as Mrs. Lawrence is no longer at risk for her fellow residents. When outbursts do occur, they are easily altered by staff who now feel better prepared and equipped with tools and techniques to help them navigate a given episode.

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evidence of change | spotlight on QI data

BSO Evidence of Change – Sample Quality Improvement Data Quality Improvement methods and tools are helping local teams understand the current state of their system, and test and measure change. Data collected for quality improvement purposes help us better understand the client population, and point to system-level and client care impacts of BSO. Client Population Charts 1 and 2 demonstrate the different behaviours that trigger mobile service referral. Early data from HNHB LHIN suggest that in community settings confusion, agitation, caregiver burden, aggression and delusion are the primary triggers. In contrast, in long-term care homes physical aggression, resistance to care, verbal aggression and ‘other’ non-specific causes are more likely to trigger a referral. Chart 1

Chart 2

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Demonstrated Impact The following micro-level evidence of local change shows clear, sustained improvement. Movement on indicators like these is a necessary precursor for movement in patient outcome and system indicators. ….on the number of responsive behaviours Chart 3 looks at a drop in the total number of responsive behaviours across LTCHs in the MH LHIN (drop from mean=20.24 pre-BSO services to mean=11.03 post-BSO implementation). Chart 3

Chart 4 demonstrates the staggering impact when a Community Support Worker (CSW) entered service at an Adult Day Program in MH LHIN – a drop from mean = 81.29 responsive behaviours pre-BSO services to mean=2.32 responsive behaviours post-BSO services. Chart 4 depicts only one example of several Adult Day Programs where the incidence of responsive behaviours was seen to diminish abruptly and profoundly. Chart 4 …on restraint use

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Chart 5 is early evidence that restraint use in one LTCH in CE LHIN may be in decline. The graph shows the total number of residents in restraints over the course of a year (October 2011 – September 2012), noting when BSO service staff were trained and BSO services initiated locally.

Chart 5

…on team-approach to care

Chart 6 demonstrates how the system is learning to work with the new BSO team in NSM LHIN. The following chart shows that referrals are matching the appropriate criteria. In July, there is a high % of appropriate referrals because only hand-picked pilot sites participated who were well aware of process and criteria. The percentage drops when services were opened to more organizations, but improvement in September suggests they are figuring it out. Knowing when and who to refer to service will have an impact on the ability of BSO staff to provide the right care, at the right time, in the right place.

Chart 6

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Early stage measurement

In all LHINs, BSO sponsored process change is guided and modified in real time based on relevant measures of impact. A wealth of clinical and system data are being generated and analyzed across the project. In most cases it is too soon to draw firm conclusions about the outcome of a specific service or process change.

HNHB’s BSO Long-Term Care Mobile Team (Hamilton Hub) provides a case in point. Chart 7 displays the length of time the Hamilton LTCH mobile team is involved with a resident living with a particular behaviour. Each client is represented as a single data point during the period May 25 to September 30, 2012.

Chart 7

Chart 7 reveals the average number of days per resident is 25 with a great deal of normal variation. One case of special cause variation is shown as a red dot. Because it is still early in the data collection, no trending is seen and no conclusions can be drawn.

The local steering committee and the team will continue to monitor trends or special cause variations. As Hamilton is one of five hub regions within HNHB, comparison between teams may reveal differences that indicate the need to resource the hubs differently. Comparisons may also demonstrate factors associated with successful implementation. Data quality are also being measured. The missing data points relate to files that remain open, and once the team has completed their involvement with a resident, the discharge date will complete the data and allow the client to be plotted as an additional point on Chart 7. To support the collection of high quality data, HNHB will work with the mobile team to ensure missing data points belong to active clients of the team, rather than former clients whose files remain open in error.

Numbers Tell the Story

Q2 revealed evidence-based quality data that the Mississauga Halton LHIN had hoped for and knew would come. Data analysis reveals a sustained decrease in responsive behaviours of 98%, allowing clients to stay in the community longer without the need for more intensive services. Meanwhile, costing statistics for this LHIN reveal a potential system savings in excess of $330 thousand dollars after the infusion of only 4 Community Support Workers.

Here are the costing stats for the CSW using the data from the control charts

Average cost/day pre-CSW:

$512.15/ (annualized

$133,159.00)

Average cost/day post CSW:

$15.11 (annualized $3,928.60)

CSW cost (salary and benefits):

$45,045.00

Net savings to system with 1

CSW: $84,185.40

Potential system saving with 4

CSWs: $336,741.60 (approx.

$500/day)

By delaying the need for more intensive services and saving valuable healthcare dollars, BSO is providing better care and better value.

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Where quantitative outcomes depict an at-a-glance summary of what is happening, qualitative outcomes provide the how. Section 3 paints the picture of how the project is responding to immediate realities, anticipating upcoming needs and immediately applying lessons learned to accelerate and sustain change.

quality improvement

impact of HQO coaching and leadership

Building Local Improvement Capacity In the second quarter, Health Quality Ontario (HQO) continued to develop Improvement Facilitators from all 14 LHINs through the 2012-13 Integrated Quality Improvement (QI) Workplan. In addition to webinars focused on Applied Quality Improvement Science, opportunities for problem-solving and Improvement Facilitator team consultation were introduced. Discussions for ongoing Improvement Facilitator skill development were initiated in July, and have continued into the fall. Accelerating Improvement through Kaizen Events LHINs have continued to embrace Kaizen Events as a means of accelerating improvement. In addition to the event hosted in Erie St. Clair in July, many of the Improvement Facilitators trained through BSO are successfully leading their own kaizen events. Buddy LHINs continue to be connected and to support one another. HQO has created a step-by-step preparation guide to assist in kaizen planning and delivery.

Qualitative

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I Get by With a Little Help from My Friends

Sometimes all it takes is a little help and understanding. You need only look at Marco who, at 78 and diagnosed with dementia and chronic depression, has fought hard against his responsive behaviours; but not without the recent help of some important friends. Shortly after transitioning from a community residence to LTC in the Central LHIN, Marco began to display aggressive behaviour towards other residents and, on multiple occasions, had to be removed from the Home for concerns over resident safety. Marco’s journey took him to the Ontario Shores Geriatric Dementia Unit, where a multidisciplinary team worked on developing a comprehensive treatment plan specifically geared towards the ongoing agitation associated with his dementia. Nearing the end of his assessment period and prior to discharge, Marco was referred to the LOFT Community Services BSS – MST by his LTC Home, hopeful the Team could provide support throughout the transition. Collaboratively, the BSS-MST worked with Marco’s LTC Home, the team at Ontario Shores and his family to develop a tailored transition plan that took into account a variety of factors, including successful behavioural strategies while in hospital and likely “triggers” for aggressive behaviour upon return to LTC. At the same time, the Team worked directly with Marco, getting to know him and developing a meaningful relationship with him. A well thought out and executed transition plan and a comprehensive care plan have resulted in Marco returning to LTC, where he now resides without any significant behavioural incidents; a home that provides the right care in the right place for Marco. Marco is but one example of the clients supported by the BSS-MST who have collectively seen, on average, a 70% reduction from admission to discharge in their Cohen Mansfield Assessment Scale results and have significantly improved their responsive behaviours.

Operational Definitions – Activity Measures In recognition of the desire to show progress despite the expected lag time between improvement activities and reflection in the outcome measures, collaborative working groups, with the support of Health Quality Ontario, identified activity measures. Operational definitions were articulated and where possible, consistent measures were used across leading practices for simplicity in interpretation. Activity measures are process measures that convey progress toward implementation of the change ideas that the teams believe will lead to an improvement. This array of measures reflects the BSO approach of local development to best meet local needs rather than requiring “provincial” solutions. They are reviewed with the intent of using “measurement for learning” within and between teams. One activity supports the other, and so it is the integration and synthesis within the family of measures that will generate the richest discussions. While every activity will generate outcomes in all three pillars of the BSO framework to result in person centred integrated services, measures were associated with a single pillar to confirm representation of the entire framework. To be sustainable, BSO supports need to reflect the “triple hat”, providing direct services to the client, indirect services to the provider and build capacity for all in terms of service improvement. Going forward, there will be times that it makes sense to approach measures using convenience samples (e.g. might measure 1 in 10, or all clients on a particular day) to generate “just enough” data to inform the team’s next steps. One of the functions of the collaborative working group is to provide a forum for discussions and decisions to refine operational definitions as new situations arise.

Leveraging Synergies between Residents First and BSO for Mutual Spread and Sustainability

BSO and Residents First partnered with the North Simcoe Muskoka, Mississauga Halton and Central West LHINs to host two 3-day events in late August. These events tested two days of Residents First Quality Improvement Facilitator Training, followed by a 1 day event to explore the application of quality improvement knowledge, skills, and tools. The BSO and Residents First joint events will advance the mutual goal of improving the lives of residents with responsive behaviours. Targeted toward both Long Term Care staff and BSO partner organizations, the goal was to foster relationships and reinforce a broad understanding that we are creating an integrated team working together for the resident, and that Residents First, BSO Support Teams, and Long Term Care home teams, are working collaboratively. We know that behavioural support best

practices provide positive resident outcomes through early identification and prevention, and that using the Residents First Responsive Behaviours Change package to generate consistent internal support will make for predictable consultations with BSO Teams.

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Two distinct models were tested by three volunteer LHINs:

North Simcoe Muskoka LHIN: August 21-23, 2012: 2 days of Residents First Quality Improvement Facilitator Training followed by a 1 day KAIZEN event to further explore the application of quality improvement knowledge, skills, and tools to improve the linkage between the Residents First Residents First Responsive Behaviours Change Package and Mobile Support Team.

Central West and Mississauga Halton LHINs: August 28-30, 2012: 2 days Residents First Quality Improvement Facilitator Training followed by 1 day focused on CASE STUDIES to apply learning.

A target participation of 50% of Long Term Care homes was set and despite a very short lead time, was almost met in North Simcoe Muskoka (46%, 12 of 26 homes). Persistent personal follow up between the LHIN Lead and Improvement Facilitator with the Directors of Care about the linkage with Residents First and the value of building resources led to extraordinary engagement with 81% (17 of 21) BSO homes in Central West and 96% (27 of 28) in Mississauga attending.

Results were shared with all 14 LHIN leads in September and additional events have been scheduled as follows:

Central East, November 6-8, 2012

North West, November 21-23, 2012

Waterloo Wellington, November 28-30, 2012

HNHB, December 4-6, 2012

BSO collaborative working groups

Centralized Intake: The Central Intake/Enhanced Access Working Group has been focused on sharing of intake models, forms, challenges and lessons learned across LHINs during the past quarter. Common measures were established for those LHINs implementing central intake. 3 of the 4 early adopter LHINs have presented to the group in detail around their model. The focus of the group’s effort will now move to sustainability and establishing goals for short term, medium term and long term for intake. A critical success factor for the group going forward is a clear goal and focus for intake provincially. Also, a 2-day Kaizen even took place with Erie St. Clair in June, the focus of which was on defining services accessed through centralized intake and creating a standardized process to access these services. Given the new System Navigator role, the Outreach Teams of the three geographic regions of Erie St. Clair spent time understanding and refining the System Navigator role throughout the continuum of care. Finally, all members spent time establishing a common initial assessment to be used across Erie St. Clair by the Mobile Team. See Table on page 24.

May we Approach

At 58 and on the wait list for long-term care, Mr. R. was referred to the Toronto Central LHIN Community Behavioural Support Outreach Team (TC-BSOT) for behavioural assessment associated with early onset dementia. Apathetic, anxious, verbally abusive and disinhibited he could arguably be likened to many of those he often faced in the courtroom as a once very successful lawyer.

“Using the PIECES framework in addition to several direct observation sessions of client/caregiver interactions, it soon became apparent that Mr. R.’s behaviours were having a significantly negative affect on his service providers and the well-being of his family,” said Jacquelin Lyn, Clinician Leader TC-BSOT. “Mr. R.’s care was simplified for the family by engaging all members of the circle of care and facilitating the coordination, prioritization and streamlining of involved health care providers and interventions.” Sitting for long periods of time with limited meaningful activity was addressed through Montessori-based dementia programming principles, designed to create meaningful activities for Mr. R. and thereby enhancing his quality of life. Caregivers were educated and coached on how to interact and communicate with the client using specific strategies and, in advance of placement, the C-BSOT met with staff in the LTC home to share assessment findings and care strategies. Through the development of an individualized behavioural management plan caregiver burden was improved and the client’s behaviours were stabilized to enable a smooth transition of the client from the community to a successful placement in a LTC home. The client continues to do well at his new home.

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Table - Centralized Intake Tools and Processes Developed

Mobile Support Teams: During Q2, the collaborative identified 5 common metrics for each LHIN, with operational definitions and inclusion/exclusion criteria. The metrics are set to generate learning’s and can be modified for each LHINs’ specific needs. Metrics will not be used to compare LHINs, but to contribute to continual quality improvement in each local area.

The collaborative also completed a matrix that identifies the features of each mobile team in each LHIN including:

populations served and catchment area organizations involved unique characteristics of the catchment area / population system, organization and service-based activities Sectors served, and services provided to them Staffing competencies, characteristics, skill set, and capacity building activities.

Tools and Processes Developed Developed 2011-12

Q4

Developed 2012-13

Q1

Erie St. Clair

Referral and intake process algorithm

Referral Form

Standardized referral from for SMHA team, CCAC GRT and Alzheimer’s team

Spectrum of Outreach services – criteria to call

Community Service Involvement Tool (CSI tool)

Central Intake – one number to call (by hub)

Intake and Triage Form

Risk Triage Referral Tool

Risk definition and categories* New!

Centralized Intake and Triage Tool, including R.I.S.K. Rating Scale* New!

Algorithm to respond to risk* New!

Decision Algorithm: MST deployment

Process map for BSO team services

Responsive Behaviour Assessment Tool* New!

Safety Plan – Immediate Safety and Care Plan

Behavioural Plan including risk algorithm

“Wishes and Wants” Checklist (by region) New!

Roles and Responsibilities: Q&A* New!

“Elevator Speeches”* New!

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Behavioural Support Units: The Behavioural Support Collaborative Working Group is comprised of representatives of the four LHINs who are developing a Behavioural Support Unit (BSU), Toronto Central, Central, Champlain and North Simcoe Muskoka and also service representatives of the organizations who will be involved in the operation of the proposed units. Participation also includes HQO and the Ministry of Health and Long-Term Care, PRT, CRO as required. The collaborative is chaired by the Mississauga Halton LHIN who already has a designated BSU operating as a specialized unit under the LTCHA, 2007. In the early stages of the second quarter of 2012/13 the collaborative continued to work on data collection processes to support the standard activity measures for the units. Examples of reporting of data collected by the Sheridan Villa BSU in Mississauga provided opportunity to discuss methods to display unit performance and also how the information could be used to implement quality change processes. With three of the four LHIN areas having submitted their proposals for approval for designation of specialized unit status to the Ministry and not having received a decision, it was decided by the group that meetings would be postponed until communication of designated unit status had been received. No meetings were held within the months of August and September. Ministry approval of specialized unit status was obtained by the Toronto Central and Central LHINs in September. With initial approvals received, work focused on the operation of each unit. Common activities involved staff recruitment, staff training and education of community partners of the future openings and referral information to facilitate identification of potential clients. It was decided that the next meeting of the BSU collaborative would occur in October and would continue the work to develop standard data collection practices and also share experiences, processes and materials to support operations.

Let the Record Show “Lena” is a 65 years-old LTC resident with responsive behaviours associated with schizophrenia, and whose condition took her from LTC to Ontario Shores for a 60-day assessment… and back. While in the care of Ontario Shores, “Lorna” was introduced to a variety of interventions and activities from an equally diverse array of interdisciplinary professionals including the Central East LHIN BSO Team, who joined Lena in her journey every step along the way. BSO Psycho-geriatric Services worked with LTC staff on case reviews and provided training in techniques to manage Lena’s behaviour ahead of her return. A BSO RPN and PSW helped to bridge the communication gap between hospital and home by providing weekly progress reports, liaising and establishing a meaningful relationship with Lena prior to her hospital discharge, preparing necessary changes to the LTC environment to accommodate return (staffing, managing and monitoring behaviour protocols) and applying an Integrated Care Team approach with Ontario Shores by assisting the Home to put in place interventions specific to Lena’s needs. To promote independence, allow for flexibility in daily living and to ensure the safety of staff and residents, medical interventions were adjusted and treatment tools and techniques were introduced including a resident contract, check-in times and schedules. Prior to arriving at Ontario Shores and BSO involvement, Lena was averaging 14 behavioural incidents/mth. Let the record show, following her return to LTC, Lena’s behavioural incidents have dropped to an average of just 2 every 1.5mths, representing a potential annual decrease from 168 incidents/year to 16 or 90%! Lena continues to respond well and has become more trusting and engaging of both staff and residents alike.

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Answering the Call

Having transitioned from her personal residence, “Susan” was referred to the North West LHIN Psychogeriatric Resource Consultant (PRC) by her new long-term care home. Concern for her safety and that of residents arose because of responsive behaviours associated with dementia including exit seeking, wandering, increased levels of agitation and aggressive behaviours that were physical in nature. Susan’s treatment up to that point had largely been through pharmalogical interventions. The PRC met with the Home’s Unit Coordinator to define Susan’s behaviours, determine potential risks and review the approaches and interventions attempted. The PRC also received information from front-line staff and her family about Susan’s resident file, social history, likes and dislikes, cognitive screening tools, nursing notes and medication administration record. Staff and resident interactions were observed during challenging times that included personal care routines and bath time. . A comprehensive picture was developed in order to subsequently develop a client-centred care plan, tailored to Susan’s specific needs. A series of recommendation were proposed and integrated through the care plan, including the education and training of staff to better cope with responsive behaviours in general including proper non-pharmacological interventions that can be used to stabilize residents and ultimately maintain them within their home community. Prior to this consult, the long-term care home was considering an alternative placement for Susan as they did not feel prepared to properly care for her needs. With BSO assistance, Susan’s behaviours have become less frequent, less violent and more manageable for staff, allowing her the opportunity to remain in the Home rather than being transferred to the emergency department for non-acute care needs. This case also provided the Home with valuable insights into the world of dementia and responsive behaviours.

capacity building

The third pillar of the BSO Framework for Care speaks to capacity building and a knowledgeable care team as critical components to support service redesign. The vision for how BSO would support each of these components at a project level is to provincially link and align capacity building elements, but do so in a way that enables LHINs to adapt components based on the learning needs and unique context of their region. During Q2 there has been a continued local focus on training new staff, and a provincial focus on planning for anticipated needs as implementation continues. In addition the project continued to set the foundation for the next phase of support. Capacity Building Community of Practice: Supported by the Alzheimer Knowledge Exchange, this Community of Practice brings together those with a role in local BSO Capacity Building activities to raise awareness of other capacity building strategies happening across the province, build on and adapt the work of others, and collaborate to develop common resources, tools and processes. The Road Ahead: During Q2 the BSO project assembled an expert panel to advise the development of the next capacity building resource: The Road Ahead. A complement to the BSO Capacity Building Roadmap, The Road Ahead details a menu of ten learning strategies to support ongoing and sustainable capacity building. The Road Ahead, set for release in Q3, will enable individuals and teams to make better decisions about how, why and with whom they plan their continued capacity building. Linking the Capacity Building Suite of Tools: The BSO project has begun development on a visual resource which will link the suite of capacity building tools available to support local decision making; including: The BSO Capacity Building Roadmap, The Person Centred Team Based Service Learning Framework, The Behavioural Education Training and Supports Inventory, and The Road Ahead. This visual will help users understand when to use each tool and how each tool can be integrated with and complement each other. Education & Training Subgroup: The Education & Training Subgroup was established in Q1 to provide resources for the LHINs to implement their BSO action plans for capacity enhancement through learning, knowledge transfer and development programs. Following the release of the Behavioural Education Training and Supports Inventory (BETSI) Framework (June 2012), the Education and Training Group took a brief hiatus. They will reconvene in Q3 to address the emerging education needs of those caring for individuals in other sectors (e.g. primary care, community care, acute care etc.).

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The Burden of Caring

It is not every day that the primary caregiver of a 65 year Old man turns out to be his 87 year old mother but, that is exactly the case before the Hamilton Niagara Haldimand Brand LHIN BSO Community Outreach Team (COT) when William’s mother called the crisis team with her son facing eviction from his apartment.

William has frontotemporal dementia and suffers memory loss due to cognitive impairment. As his only support, William’s mother approached the COT one week prior to eviction, which was precipitated by a variety of responsive behaviours including safety concerns related to cooking fires and posing a disruption to other tenants. In addition, William has demonstrated wandering behaviour, the occurrence of which can cause angst for his mother who worries about his safety. Relieving caregiver burden involved a number of aspects related to Williams’s case. The BSO team worked to find housing and services that would support William in the community. They worked with the superintendent of his existing building to extend his eviction timeframe so that he could find a new place to live. They found geared-to-income supportive housing in a retirement home. They arranged for William to be placed on the Safely Home Wandering Registry through the Alzheimer Society, assisted the family with moving arrangements, connected with retirement home staff prior to transition, requested geriatric psychiatry for medication review and cognitive testing and accompanied his mother on most appointments. As a result of COT interventions, William’s wandering has not been an issue since moving to the retirement home. William’s mother is feeling better about support for her son; feeling both relieved and thankful that he has a new place to live.