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

BSO Project Background BSO project is a $40 million Ontario wide project in partnership with: All Ontario Local Health Integration Networks(LHINS) Alzheimer Society of Ontario Health Quality Ontario Ministry of Health and Long Term Care Central East LHIN is one of 4 early Adopter LHINS $1.6 million investment in 2011/2012 $ 4.06 million on an annual basis

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

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.

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

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

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

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

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

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 (124 - 1 day, 65- 3 day training) 190 Total 1520 Total days of formal training = 2610 + all the GPA training completed by the trainers Pillar #3- Knowledgeable Care Team & Capacity Building new schedule to be planned for 2013- 2014 Learn

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

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

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

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

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

BSO in Central East – Early Successes Impact: 886 residents assessed and served in 13 Early Adopter LTC homes in 2012-2013 1520 staff trained (2610 training days) Behavioural Assessment Tool, Whiteboard, Client Care Process Flow utilized in 72% of Central East LTCHs Community – draft design of Client Care Process Flow developed Client Stories: Decrease of behavioural incidents in clients with responsive behaviours Increased client cooperation with activities of daily care Decrease in use of physical and pharmacological restraints to control behaviours Admission of people with difficult behaviours from tertiary care settings and behavioural support units 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

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

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

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

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

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

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.

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

For more information…. http://www.centraleastlhin.on.ca/report_display.aspx?id=21366 BSO page on CE LHIN website http://www.centraleastlhin.on.ca/page.aspx?id=23202 BSO hidden page on CE LHIN website http://www.akeresourcecentre.org/BSO Alzheimer Knowledge Exchange BSO webpage Joy L. Husak – Executive Director, Fairhaven – 705-743-0881, extension 231 – jhusak@fairhavenltc.com