1. Canadian Coalition for Seniors’ Mental Health 3 rd National Conference: The Future of Geriatric Mental Health in Canada September 3 rd 2008 Exploring Knowledge Transfer and Exchange Implementing Mental Health Guidelines in Long Term Care Homes

2. Disclosures: Dr. Conn has attended Advisory boards or received honoraria from: Astra-Zeneca Janssen-Ortho Lilly Pfizer Organon Lundbeck Novartis Wyeth Dr. Le Clair has attended Advisory boards for: Janssen-Ortho Pfizer Lundbeck Wyeth Ms. Baker and Ms. Walsh have no conflict of interest that may have a direct bearing on the subject matter of this presentation.

3. Agenda 1:00 – Welcome and Introductions 1:10 – Background on the CCSMH Guidelines Project and Implementation Plan 1:20 – Understanding the Need for Knowledge Translation 1:30 – Approach #1 – Using Provincial Networks 1:50 – Approach #2 - Local Implementation 2:20 – Questions? Comments? 2:30 – Break in Foyer

4. Objectives At the end of this workshop, participants will gain further understanding on how to: Implement best practices in long term care settings, with an understanding of the process, barriers and vehicles to success; Identify ways to build interdisciplinary teams and networks; Advocate for quality improvement in their Long Term Care facilities.

5. CCSMH Guideline Project: Setting the Context Funding awarded in Jan. 2005 by Public Health Agency of Canada, Population Health Fund Goal: To lead and facilitate the development of evidence- based recommendations for best practice guidelines in areas of seniors’ mental health

6. Background: The CCSMH Guideline Project Assessment & Treatment of Delirium Assessment & Treatment of Depression Assessment & Treatment of Mental Health Issues in LTC Homes (with a focus on mood & behaviour) Assessment of Suicide Risk & Prevention of Suicide

7. Long Term Care Homes (LTC) in Canada 7% of the Canadian population reside in LTC at any one time. 40% reside in LTC at some time. Institutionalization increases with age (38% of women and 24% of men over 85 live in LTC). Institutionalization correlates with decline in ability to perform ADLs & IADLs and with mental health and behavioural challenges. “Baby Boomers” will start utilizing LTC in significant numbers around 2020.

8. Value Proposition There is a need to focus on both mental health and mental illness in LTC homes. There is significant diversity in the LTC population. Effective mental health management requires an interdisciplinary approach. Relationships among residents, family members and staff are central in meeting mental health needs. The milieu (social and physical environment) can promote or undermine mental health.

9. Contents of LTC Guidelines General Care Assessment Treatment of Depression Treatment of Behavioral Symptoms Organizational & System issues

10. Current research indicates that typical dissemination plans for clinical guidelines include publication in academic journals and/or mail outs; however these methods seem to have no noticeable impact on practice change. Rosser, W.W., Davis, D., Gilbart, E. (2001). Promoting effective guideline use in Ontario. Canadian Medical Association Journal, 165(2), 181-182. Why Is Knowledge Translation Needed?

11. Additionally Ouimet et al found that the probability of guideline utilization increased through workshops. They also discussed the importance of face-to-face interactions between researchers and decisions makers as an important indicator for guideline utilization. This concept of personal interaction was consistently supported throughout the knowledge translation literature. Ouimet, M., Landry, R., Amara, N., & Balkhodja, O. (2006). What factors induce health care decision makers to use clinical guidelines? Evidence from provincial health ministries, regional health authorities, and hospitals in Canada. Social Science & Medicine, 62, 964-976. Lomas, J. (2000). Using ‘linkage and exchange’ to move research into policy at a Canadian foundation. Health Affairs, 19(3), 236-240. Innvaer, S., Vist, G., Trommald, M., & Oxman, A. (2002). Health policy makers’ perceptions of their use of evidence: a systematic review. Journal of Health Services Research & Policy, 7(4), 239-244h. Why Is Knowledge Translation Needed?

12. Consumer Groups NGOs Service Collab- oration & Local Opinion Leaders Govern- ment Pillars and Partners to Change (Chambers et al ) Areas of Support, and Synergy

13. Ingredients for Change: A Conceptual Framework Complementing the Knowledge Translational Exchange Cycle Evidence or What do we need to do?  Research (Traditional, Population, Epidemiology)  Clinical Experience (Tacit Knowledge)  Patient Experience Rycroft-Malone, Kitson A, et al

14. Ingredients for Change: A Conceptual Framework Complementing the Knowledge Translational Exchange Cycle Context: How are we going to do it?  Values, Share Vision  Diffusion and Readiness (Individual, Organization, Community) Rycroft-Malone, Kitson A, et al (Rogers)

15. Ingredients for Change: A Conceptual Framework Complementing the Knowledge Translational Exchange Cycle Exchange: Who is going to do it? (Facilitation)  Helping enable, rather than telling  Titchens (Critical Companionship) Rycroft-Malone, Kitson A, et al

16. Knowledge Translation Cycle KGKTKA Knowledge Utilization Person Centred + Evaluation Knowledge Retrieval Channels: Consultation, information, learning and development (Technology) Factors: Evidence, persons, organizations, community KE (Sullivan et al)

17. Readiness and Realizing Change Knowledge Awareness Understanding Belief Action D. Joyce (KUBA)

18. Dialogue & Identification Key Factors Critical to Knowledge Transfer & Exchange 1. Identify strategies you have used to achieve knowledge transfer and exchange. 2.Identify the critical elements or possible strategies to achieve knowledge transfer and exchange. 3.Identify resources you may have for knowledge transfer and exchange.

19. The Ontario Task Force: A Provincial Approach to Guideline Implementation Provincially Supported, Locally Delivered, using existing channels

20. Ontario Task Force The Ontario Task Force was created with the recognition that in Ontario, there are multiple initiatives, associations and programs that exist within long term care..

21. The membership of the Ontario Task Force was carefully selected, ensuring that representatives from all pillars of change were included. Examples of membership are listed below: Academic – Queen’s University, Alzheimer Knowledge Exchange (AKE) NGO’s – Ontario Long Term Care Association (OLTCA), Ontario Association for Non-Profit Homes and Services for Seniors Government – Ontario Seniors Secretariat (OSS), Ministry of Health and Long-Term Care Clinicians/ Change Champions – Psychogeriatric Resource Consultants (PRCs), Post Alzheimer Strategy Consumers – Alzheimer Society of Ontario

22. Working with the partners in the Ontario Task Force a pilot project was created (with funding received from the Public Health Agency of Canada) to use the Psychogeriatric Resource Consultants and local networks to implement the guidelines at the local level across the province. “Local is the Key Regional/Provincial Support” Using the Existing Knowledge Transfer Channels

23. Target Guidelines and Audience This pilot implementation project focuses on raising awareness of the CCSMH LTC guideline and increasing the exchange, utilization and retrieval of the guideline recommendations by Psychogeriatric Resource Consultants with their partners.

24. Cornerstones to Implementation Psychogeriatric Resource Consultants (PRC) Existing Learning Networks

25. Methods Phase 1 Introduction Introduction of guidelines to PRCs Interactive web presentation- guideline development process, understand the levels of evidence and have the opportunity to ask specific questions on recommendations Learn about the Ontario Task Force Implementation Project and will be invited to move into Phase 2

26. Phase I: Using Adobe Connect Hosted by the AKE on January 15 th, 2008 24 attendees 20 committed to moving forward in Phase II

27. Method Phase 2 Awareness Invite PRCs to commit to raising awareness of the guidelines within their local Learning Networks (approx. 15-18) Participating PRCs will work with Ontario Task Force to decide on materials and resources required. Resource Package to be developed Feedback Invitation to participate in Phase 3

28. Phase II Two regional half day meetings facilitated by Kathy Baker in Kingston (Eastern Ontario) and Kitchener (Southwestern / Central Ontario). 13 attendees between two days Representation from 10 of the 14 LHINS

29. Regional Meeting Key Messages Need to find ‘champions’ in the homes that will be piloting Plan to capitalize on existing teams and resources Ensure senior leadership support (letters to administrators) Create key partnerships (i.e. with GMHOT) (Bi-level action: Senior leaders and practice change champions)

30. Regional Meetings: Potential Barriers Financial and human resources –staff time –replacement costs for training –people are tapped out already and overworked –partnerships may not be as strong – are people dependent (people can leave, change roles etc.) – need key players LTC is often the place that those with the most complex needs (that don’t fit our present system) are placed Working culture has to be ‘change friendly’ Compliance crises

31. Regional Meeting: Strategies for Raising Awareness + Readiness Information is needed to raise awareness universally and then target one or two homes to participate in the evaluation send a letter to administrators, directors of care, resident care coordinators let OANHSS and OLTCA know which homes are participating as well as compliance advisors partner and link with education and best practice coordinators and those responsible fro the staff development and education Use existing networks and promote to outreach teams Have them on hand for ‘in the moment’ learning CCSMH and team to create a power point presentation

32. Raising Awareness Resources A letter to administrators A ‘one pager’ guideline summary A content based power point presentation Hard copy distribution of the guidelines to staff, teams etc.

33. Method Phase 3 Application & Utilization Start date: Fall 2008 PRCs (approx. 5-10) to work with Long Term Care Homes that are interested in implementation of guidelines Choose aspects of implementation relevant to their LTCH (locally driven, readiness) Consideration: Size of the home; culture of the work environment; readiness of the home; senior leadership support

34. Phase 3: Learning Knowledge Exchange, Literature/Practice-Based Evidence Collaborate with the RNAO and host a workshop on implementation Attendees would include PRCs and the ‘champions’ from the selected pilot homes Webinars for P.I.E.C.E.S trained staff in the homes (Enriching the Channels and Capacity for KT)

35. Method Phase 4 Knowledge Retrieval Qualitative and quantitative reports from PRCs Includes data on individual projects, outcomes, developed products and ongoing ability to use guideline recommendations within clinical practices Sharing successes/projects and strategies with other PRCs and LTCH in the province

36. Evaluation The purpose of the evaluation; to determine the extent and impact of knowledge awareness, exchange, utilization and retrieval that occurs as a result of implementation activities (e-health, regional awareness + support activities, resource package, and local application projects). The process; employ a systems perspective with an emphasis on identifying organizational and institutional opportunities and barriers

37. Performance Improvement A result-driven perspective to work, the workplace, and the worker. Doing meaningful work in effective and efficient ways.

38. The Work of Performance Improvement  Focusing on outcomes.  Taking a systems view.  Adding value.  Working in partnerships.

39. Factors Supporting Performance Clear performance expectations (standards, policy) Essential support (resources, responsibility, authority, time) Clear consequences (reinforcement, incentives, rewards) Prompt feedback (how well performance matches expectations) Individual capability (physical, mental, emotional capacity, experience) Necessary skills and knowledge (training, learning to perform)

40. Key Points Learners by themselves can’t make the changes Training people on what they already know will not improve performance. Focus on the gap between current performance and better practices.

41. Our job is to understand… Humans have a large capacity to learn The learner is always the start point Learning means change… leadership team support is essential How to clear the path… need an environment that favours learning and eliminate things that conflict

42. Start point! Focus first on what people are expected to accomplish on the job (competency)…...rather than what people are expected to learn. (Robinson & Robinson, 2004)

43. Questions for Discussion