1. Behavioural Supports Ontario BSO Impact in Ontario and the CE LHIN
Presented by:
Joy L. Husak – BSO Design Team
July 24, 2013

2. 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

3. 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.
Notes :
Through BSO, new services, programs and training are in place to provide appropriate care and support for an increasing number of seniors across Ontario, their families and caregivers, who live and cope with dementia, mental illness and/or other neurological conditions
BSO creates 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 & practices
BSO represents a comprehensive system redesign that has successfully broken down barriers, encouraged collaborative work, shared knowledge and fostered partnerships among local, regional and provincial agencies.
The result is a cultural transformation; a new way of thinking, acting and behaving

4. Composition of the Integrated Care Team
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
NPSTAT (Nurse Practitioner Outreach Team):
timely response to LTC to conduct advanced medical assessments for residents with escalated behaviours and medical care as appropriate
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
Psycho-geriatric resource consultants (PRC):
expert input to quality improvement activities
develop improved processes of care
provide staff education.

5. 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
All Pillars are supported by Continuous Quality Improvement methodologies to define processes, roles & accountabilities and ensure mechanisms are in place to measure, implement and evaluate service changes
Pillar 1
Coordinated, cross-agency, cross-sectoral collaboration and/or partnerships based on clearly defined roles and processes are required to facilitate seamless care. 
Pillar 2
Outreach and cross-sector interdisciplinary transitional teams across the continuum enable equitable and timely access and transitions to the right provider for the right service
Introduces collaborative/shared care service delivery through interdisciplinary cross-sector and system support teams, case management and intersectoral frameworks and
communication vehicles
Value the least restrictive / intrusive approach: enhanced approaches and services that promote early detection and health promotion; specialized residential treatment.
Pillar 3
Education and training strengthen the capacity of family caregivers and professionals.
The goal is person-directed care, prevention and early detection; implementation of standardized best practices in behavioural health; and continuous quality improvement.
Help families make informed choices
Create supportive learning infrastructures and foster collaboration between individuals, teams, organizations, systems
Nurture cutting edge research and apply new technologies
Support efficient, effective use of human resources and evidence-based decisions

6. 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
AKE
Provincial Operations Table for continued focus and development of provincial initiatives
Website - repository for Information- continues to be a “go-to” place for info
Multiple success stories reported by staff and families

7. BSO in Central East - Strategy
Phased - start with LTC and then move to Community
LTCH Stream
Community Stream
Integrated Care Team to leverage current resources and expertise:
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
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
Include background:
Include an overview/intro of CE LHIN strategy, including 2 day VSM session (Sept 2011) to set the course for the Action Plan
Describe Design Team structure and involvement
Emphasis on Quality Improvement and increasing capacity at the front line
1. LTCH Streams – started within Early Adopter LTCHs and spread to all LTCHs (LTCH population)
2. Community Stream – start with a few agencies or a few staff within each agency and then spread to all agencies and staff (Community population)
Utilize Integrated Care team approach for collaboration

8. BSO in Central East – Quality Improvement
Quality 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 
BSO partner Health Quality Ontario was instrumental in providing guidance and support by:
Building local improvement expertise and capacity (406 new Improvement Facilitators trained across the province)
Sustainability planning
Using measurement to support sustainability and continuous improvement
Focus- select area to test
Learn – learn from tests, adopt, adapt
Spread – to all units, home areas
Sustain – understand what is required to sustain, put plans in place, measure to continue to focus , learn, spread

9. 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
Value Stream Mapping sessions
Kaizen Events
Plan Do Study Act (PDSA) – over 100 cycles completed
Value stream process
Whiteboards
Behavioural Assessment Tool
Focus Learn

10. BSO in Central East – Capacity Building for LTCHs, Community Providers & Integrated Care Teams
CE LHIN training February 2012 to March 2013
Course
Participants
PIECES
416
UFirst
328
Montessori
542
Gentle Persuasive Approaches (Train the trainer) 44
Sub-total
1330
Quality Improvement Facilitation Training
( day, day training)
190
Total
1520
Total days of formal training = all the GPA training completed by the trainers
Pillar #3- Knowledgeable Care Team & Capacity Building
new schedule to be planned for
Learn

11. BSO in Central East – LTC
Commitment of LTC Early Adopter BSO Teams
Enhanced care for people living with behaviours (including evening hours)
Participation and leadership in quality improvement activities
266 Plan-Do-Study-Act cycles completed
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
PDSAs – 266 cycle completed in 33 categories- testing whiteboard, process steps, Behavioral Assessment Tool, Montessori activities, DOS, Rounds, shift hours, referrals, Psychotropic use etc.
BSO LTC Implementation Table Teams
cluster-based
Integrated Care Team membership
Purpose:
ensure spread of BSO model of care into all LTCHs
Objectives:
Develop tools & resources to support Phase 2 homes
Determine and lead engagement strategies
Evaluate progress
Spread Sustain

12. 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

13. 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

14. 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

15. 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
886 BATs completed. Overall, a BAT has been completed for 59% of those residents with a new or escalated behaviour.
Transition to learning to use the Behavioural Assessment Tool BAT, and also as knowledge matures, interventions are discovered before a BAT needs to be done?
High usage of integrated Care Team may indicate learning/Capacity building as new skills learned, also EA homes should have completed a BAT before engaging the ICT
CE LHIN BSO Measures
# & % of residents with responsive behaviours.
# & % of residents who have an escalated or new behaviour in the month.
# of Behavioural Assessment Tools (BAT) completed for residents exhibiting a new or escalated responsive behaviour.
# of Behavioural Assessment Tools (BAT) completed for residents on admission with a behavioural history.
# of residents with responsive behaviours (BAT completed) that received a change in treatment for a medical or physiological condition that triggered the behaviour.
# of residents being actively managed with a behavioural care plan (crisis care plan) who require support from the Integrated Care Team but remain in the LTCH.
# of residents with a BAT who receive a newly prescribed scheduled medication or PRN for responsive behaviours.
# of PRN medications administered to manage responsive behaviours for those residents with a completed BAT.
# of resident transfers to ED for the primary reason of responsive behaviours.
# of resident admissions to tertiary care due to responsive behaviours.
# of incidents related to responsive behaviours.
# of Form 1s.
# of residents being actively managed with a behavioural care plan (crisis care plan) that have been given a physical restraint because of responsive behaviours.
# of residents receiving High Intensity Needs Fund due to responsive behaviours.
# of police interventions initiated by the LTCH relating to responsive behaviours.
Learn

16. BSO in Central East – Early Successes
Impact:
886 residents assessed and served in 13 Early Adopter LTC homes in
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
Responsive behaviours have been noticed more
Decreased behavioural incidents
Decreased falls and restraints
Decreased use of psychotropic medication
Interventions are both non-pharmacological and pharmacological
Individualized plan of care for the residents that meets their needs
Multidisciplinary approach to providing quality care
Increased resident/family/staff satisfaction
“I have seen the benefits of the BSO program and appreciate the overall improvement in my mom’s quality of life…”
“I love the girls who come see me, they are wonderful and I totally benefit from the program”
Increased family involvement with developing plan of care
Improved resident quality of life
Reduced or no ED visits
Empowered staff to gain new skill level, competence, and independence with handling challenging behaviours
Staff empower each other to monitor behaviours and intervene as a team
Staff utilize techniques from BSO education

18. 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
Common tools, common training = common language for collaborative problem solving
Defined value Stream Process provides a context for new knowledge, pictorial view- easy to learn, not a lot different from the work previously done, but organized in a standard consistent framework, Tools are easy to use, BAT provides a starting point

19. 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

20. 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

21. 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

22. 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
Fairhaven has been working with their “buddy” homes to transfer knowledge, making visits to their homes, coaching calls, training and group meetings, offer support at any time
In house training staff in GPA at best practice meetings, workshops, family council
Montessori activity bins are set up in our special care home area with a list of specific activities for each resident – decrease in psychotropic prns
Given a math teacher a home work book where she sits and marks papers
Residents who set tables in the dining room, put out aprons , clear the tables and wipe them down after meals
Residents who remember how to knit now make it part of their daily activities
Residents who fold towels, sweep the floors, dust the railings, make beds
Enriching the lives of residents at Fairhaven
Jackie Patterson rpn and rose coones psw successfully completed Montessori certification training

23. 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.

24. 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

25. For more information….
BSO page on CE LHIN website
BSO hidden page on CE LHIN website
Alzheimer Knowledge Exchange BSO webpage
Joy L. Husak – Executive Director, Fairhaven – , extension 231 –