Behavioural Supports Ontario

Transcription

1 Behavioural Supports Ontario Quarterly Report Q / 13 Period October 1 December 31, 2012 In partnership with:

2 The addition of both the BSO Community Outreach Team and BSO Long-Term Care Mobile Team has proved invaluable to our region. The Supporting Independent Living program had many referrals requiring more rapid response than was always possible, and referrals outside of our normal operating hours. These gaps have now been closed and referrals and service support between all three teams is working well. - Jenny Shickluna and Sarah Putman Supporting Independent Living Team 2

3 Introduction table of contents Message from the Project Sponsor... 4 Executive Summary... 5 Chapter 1 BSO Overview 1.1 Structure Alignment CRO Activities and Accomplishments Project level activities and accomplishments New project supports LHIN action plans Provincial Resource Team Knowledge exchange BSO impact assessment / evaluation update Sustainability planning..17 Chapter 2 Quantitative Outcomes 2.1 Investment in HHR HHR hires Recruitment strategies/tools PSW funding Activity Tracking Evidence of Change Spotlight on QI Data Chapter 3 Qualitative Outcomes 3.1 Improvement Priorities Quality Improvement 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 HQO coaching and leadership BSO collaborative working groups Capacity Building

4 Possibilities There is an excitement that comes with the vision of future possibilities. With a shift for BSO in Q3, from implementation to operation, the possibilities and excitement are palpable! As of December 31, 2012 BSO has now hired 523 FTEs across the 14. With recruitment all but complete, BSO shifted this Fall from an implementation phase to a focus on service delivery and operations. Tens of thousands of client contacts were recorded during this reporting period, giving clear proof that the project s emphasis is on delivering person-centred, high quality care. It starts with just one person. In the NSM LHIN, Gordon has increased mobility through participation in a walking program that reduced his aggressive behaviours from 12/day to an average of 5/day. Then, it spreads. The BSO team in the NE LHIN identified and began working with 142 residents with responsive behaviours at Extendicare Falconbridge. At last count the team had successfully resolved responsive behaviours in 26 residents, and Aggressive Behaviour Scale scores are down overall for the remaining 116. Then, it snowballs. Across the Waterloo Wellington LHIN, 818 residents have been followed by BSO teams in You can quickly begin to imagine future possibilities. These successful outcomes are only a few of many stories emerging from BSO every day. In every LHIN, local project teams are taking the initiative to refine, enhance and improve as they apply continuous quality improvement techniques. The steps described in local Action Plans have largely been taken. BSO is becoming the catalyst for service change in new settings as the system integrates a wave of new behavioural supports, and the impact is radiating across all sectors of the health system. In the 3 rd Quarter, the project glimpsed the goal established by the BSO Framework for Care: better integration and collaborative transitional services, leading to better care, better outcomes for people with responsive behaviours and better value for the system. Our next challenge is to look ahead and sustain the transformation that has only just begun. We must hold the gains from recent improvements and make them the norm. At the same time, BSO must expand collaboration across multiple sectors to provide consistent, person-centred, high quality care. In the HNHB LHIN the collaborative efforts of three service models including the BSO Community Outreach Team (COT), the Integrated Community Lead (ICL) and the BSO LTC Mobile Team helped to successfully navigate Joanne from a high risk living situation with poor family supports to safe, permanent housing. In Q3, the South East LHIN experienced their first transition between two regions, when Charlie was transferred to Leeds Lanark Grenville (LLG) from Hastings Prince Edward (HPG). Members of the LLG team travelled to Bancroft and networked directly with him, and HPE then sent two members of the team on a two day admission to support Charlie in his new LTCH. The collaboration between two regional Mobile Teams made for a challenging but successful transition. Both of these examples demonstrate how BSO brings together multiple HSPs and cross-sector partners to attain common goals. But they are, however, the tip of a much larger iceberg. We can do more must do more will do more. This is how BSO will move forward, in part, toward sustainability; from being a snowball to being infectious! This is where you can begin to dream of the endless POSSIBILITIES that lie ahead! Sometimes seeing really is the only way to believe in yourself, your team, your client. Seeing Gordon succeed, when all other attempts had failed, was enough to inspire and motivate the long-term care home staff to believe in the walking program, our Mobile Support Team and in themselves. Most importantly, Gordon (and his family) once again began to believe in himself. Amazing results can be achieved in the most unexpected situations. Donna Cripps CEO, Hamilton Niagara Haldimand Brant Local Health Integration Network (HNH LHIN) & BSO Project Sponsor Haley Row North Simcoe Muskoka Mobile Support Team 4

5 Executive Summary From October 1 to December 31, 2012, BSO continued to enhance services for older people with responsive behaviours linked to cognitive impairments, people at risk of the same, and their caregivers. This report is organized in three main sections - Project Overview, Quantitative outcomes and Qualitative outcomes. Together they describe BSO s current state as of December 31, During the current reporting period, CRO spread information, knowledge and awareness about the project through a variety of channels. The project also aligned with key provincial initiatives including Ontario s Seniors Care Strategy and the Health Links primary care networks. AKE and CRO helped develop practical steps toward alignment with these two complementary initiatives during an all-lhin knowledge exchange event focused on community-dwelling clients in November. made a clear move from implementation to operationalization of their action plans and evidence that BSO is making a difference, is accumulating from a variety of data sources. Success stories from all are noted throughout the report, highlighting patient-centred care. Spotlight on QI Data, introduced in BSO s Q2 Report, demonstrates BSO is providing better care, better health and better value. Health Quality Ontario completed its BSO commitments on December 31, HQO leaves behind hundreds of trained Improvement Facilitators to continue the BSO transformation in all and across all sectors of the health system. LHIN CEOs expressed their appreciation for this remarkable 18-month partnership. BSO s communities of practice and collaborative working groups have continued to work effectively to support all aspects of the project. are testing and refining processes, then sharing their creativity and innovation with one another in real time. Proven new tools, care pathways and approaches to clinical integration are emerging in large numbers. The pace of change is accelerating. Tate Plus Eight Caring husband and father of eight beautiful children, Mr. Tate was readmitted to a South West LHIN hospital after a long-term care home (LTCH) could no longer cope with the severity and frequency of his aggressive behaviours. Joan Earl, BSO Nurse Case Manager arrived to find Mr. Tate sitting in a wheel chair, lethargic with his head drooped down and very unresponsive. Mr. Tate liked to do things his way and on his time. And so, several recommendations were built into the care plan that afforded him the ability to be engaged in his care through choice, and the time needed to process the world around him. Equally important for the team moving forward was the need to share information; what was effective and ineffective in the care plan. With the availability of a new bed in a new LTCH, the suggestion was made to transition Mr. Tate before lunch as his mood seemed to change in the afternoon. To provide familiarity and reduce the potential anxiety of a new environment, it was also recommended to have one or two of his family members present upon and following his arrival. Family members were asked to bring some items to activate/distract him; not too challenging or frustrating, but enough to add some meaning to his day. Mr. Tate navigated a successful transition over the Christmas holidays. The staff at the LTCH utilized all of the recommendations put forward in the care plan to ensure his well-being; skilled and gentle in their approaches and their care. With ongoing physiotherapy and staff support, Mr. Tate can now move about with his walker on his own, giving him the independence he cherishes. When we visited Mr. Tate following his transition, he invited Lisa (BSO Recreational Therapist) and I to his room, said Joan. It made for a really nice, intimate visit where he chatted about his past, his love of music and of his eight beautiful children. He even convinced Lisa to join him in a song. What an incredible difference. 5

6 Chapter 1 BSO OVERVIEW 1.1 Structure The North Simcoe Muskoka LHIN is funded by the Ministry to lead the Behavioural Supports Ontario Project. Donna Cripps, CEO of the Hamilton Niagara Haldimand Brant LHIN, is the project s Executive Sponsor. In partnership with the Alzheimer Society of Ontario, Alzheimer Knowledge Exchange, and Health Quality Ontario, project coordination and reporting is led by the Coordination and Reporting Office. CRO is responsible for the implementation and evaluation of the BSO Project, ensuring consultation, liaison and oversight throughout the current implementation phase. 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 designed to support implementation of BSO Action Plans; notably, capacity enhancement through learning, knowledge transfer and development programs. Fourteen-LHIN Contact Group: a table for problem-solving and joint strategy among and the project s funded partners CRO, PRT, HQO and AKE. Data, Measurement and Evaluation Committee: provides strategic direction to the Impact Assessment of the BSO Project s implementation phase (August 2011 December 2012). In addition, the Data Committee provides subject matter expertise, strategic direction and recommendations regarding project evaluation to the Contact Group. 6

7 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 comm unications and knowledge exchange. Long-Term Care Provider Advisory Council: a monthly forum for representatives of the Ontario Long-Term Care Association, Ontario Association of Non-profit Homes and Services for Seniors, Ontario Long- Term Care Physicians, the Ontario Association of Community Care Access Centres and the CRO. Members collaborate with BSO on matters related to community and long-term care with the goal of improving support to the BSO population. 1.2 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 Living Longer... Living Well is Dr. Samir Sinha s comprehensive report on how to help seniors stay healthy and live at home longer. The result of research and consultations from a broad spectrum of stakeholders, including BSO, recommendations cover health and wellness, social services, and community living for older Ontarians. A final report is expected in Q4. Ontario s Action Plan for Health Care 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 people living with complex and chronic health conditions (about 1% of the population who consume 34% of Ontario s health care budget). The target population of BSO is the population identified in the 1% - people 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. Falconbridge Over a six month period and thanks to the strength of a committed team approach, the BSO team at Extendicare Falconbridge, a long-term care home in Sudbury in the North East LHIN, has seen a significant decrease in responsive behaviours among its residents. A better home environment has been created for all residents, their caregivers and visiting family members. In August 2012 the BSO team identified and began working with 142 residents with responsive behaviours. As of January 2013 the team has successfully resolved responsive behaviours in 26 residents, and the remaining 116 have seen a noted decrease in their Aggressive Behaviour Scale (ABS) scores. The BSO system of care has reduced the use of psychotropic medications, responsive behaviours among residents, and lowered ABS scores throughout the long term care facility. With a collaborative effort at Extendicare Falconbridge from BSO staff, floor staff, management, and families, we have been successful in decreasing responsive behaviours. We have improved relationships between staff and residents, and families now have better visits with their loved ones. With compassionate, timely and person-centered care our residents have an enhanced quality of life. Natalie Gardner, RN BSO Support Coordinator, Extendicare Falconbridge 7

8 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). 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 A Familiar Face Due to high risk behaviours that posed an increased safety risk to both the client and his family, Raymond was referred to the St. Joseph s Health Centre, Guelph - Overnight Stay Program (SJHCG ONS) by a Cambridge Memorial Hospital, Geriatric Emergency Management (GEM) Nurse in the Waterloo Wellington LHIN. This was a very unique situation where the client was unknown upon admission into the SJHCG, ONS Program, said Tiffany Smith, Clinical Resource Worker, SJHCG ONS. However, due to the urgency of the referral and the space available, SJHCG was able to accommodate the request and, when staff contacted the BSO Community Responsive Behaviour Team (CRBT), they were so willing to be involved in any way possible to support Raymond and his family. It made all the difference. Collaboratively, the SGHCG ONS and CRBT teams developed a formal plan to support both Raymond and his family. Using the Dementia Observation System assessment tool, Raymond s behaviour was observed and tracked over a five day period; day one 4 hours of consistent anxiety, bouts of aggression and anger. Using Raymond s interests and history, staff developed strategies and program ideas to decrease his behaviours; day 5 30 minutes of anxiety and the anger and aggression were gone. The nest step transition to a LTCH. Faced with feelings of guilt and anxiety over unknown challenges, Raymond s family was initially hesitant to be involved in transition. Utilizing an integrated team approach including coaching and support from both SJHCG ONS and CRBT staff, the family came to feel supported and was soon willing to take part. The transition plan allowed for Raymond to be welcomed at the LTCH by his family and the familiar faces of known CRBT and SGHCG ONS teams. There was no face more familiar, welcomed or comforting than that of his 2-year-old granddaughter. Tears of happiness were in Raymond s eyes when he arrived to see his granddaughter waiting for him, said Smith. He greeted her with a twirling hug it was just such a wonderful moment his anxiety was clearly diminished. The LTCH BSO staff took the lead throughout transition and, to further facilitate ease of transition, members from each team stayed at the LTCH shortly after the family departed to further provide Raymond with feelings of reassurance, while offering any required additional support/information to the LTCH team. The partnership between the GEM team, SJHCG ADP/ONS Programs, CRBT and the LTCH BSO staff was successful and beneficial for the client, family and all Health Service Providers involved. Each partner gained support from the others while working toward the common and collaborative goal of person-centred care. 8

9 1.3 Coordination & Reporting Office October 15 October 23 October 23 October 31 November 15 Various December 17 December Project-level activities and accomplishments BSO presentation to PSW and PSW Supervisors annual conference. BSO presentation to Canadian Home Care Association annual conference. BSO panel discussion and poster at HQO Transformation Approximately 220 front-line staff joined an AKE webinar to share resources, patient-centred strategies and success stories emerging from their work on BSO. BSO project teams from all 14 met in Toronto to discuss behavioural supports for community-dwelling clients. A select group of 30 clinicians and administrators joined the discussion, representing a cross-section of the primary care and community services sectors. HQO delivered joint BSO-Residents First training events in North West, Waterloo Wellington, and Hamilton Niagara Haldimand Brant. Nearly 200 participants across the three learned Improvement Facilitator skills and applied their new tools to a local BSO case study. OANHSS webinar introducing the Capacity Building Suite of BSO learning and development tools: Capacity Building Roadmap, BETSI, Person- & Practice-based Learning, and the Road Ahead. HQO coaching and quality improvement support to BSO concludes New project supports Streamlined LHIN reporting requirements MOHLTC agreed to adjust BSO quarterly reporting to enhance and refine Activity Tracking, consolidate all reporting on local improvement efforts, and overall to shift the emphasis toward quantitative rather than qualitative data. BSO submission to Seniors Strategy and the CRO profiled BSO s early impacts and cooperation opportunities in several conversations 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. BSO Evaluation extended Hay Group agreed to delay their final report to March 2013 to include data from the period when most BSO service enhancements were put in place. MOHLTC s IntelliHealth library cannot provide key data files until Winter In Hiding Harry, a long-term care home resident living in the North West LHIN, transferred recently to another home closer to his family. This disruption to Harry s routine and familiar faces resulted in a return to previous behaviours including increased physical aggression toward staff, heightened confusion and elevated agitation, which revealed itself when Harry by hid in the closet of a fellow resident nearby. Family indicated that Harry had exhibited these types of responsive behaviours when initially admitted into his first LTCH. While the behaviours subsided with medications, increased risk for falls necessitated discontinuation. As Harry had a previous history from which to draw upon, the BSO Psychogeriatric Resource Consultant (PRC) reached out to Harry s previous long-term care home to better understand his behaviours during that time. Due to the type, frequency and known risks associated with some of Harry s prescribed medications, the PRC accessed the Geriatric Psychiatrist (a member of the BSO Mobile Outreach Team) for further consultation. Harry s care plan included recommendations to introduce use of the ABC Behavioural Analysis Chart so as to document details of his behaviours and determine triggers/patterns. In addition, non-pharmacological considerations were recommended including the use of humour when conversing/approaching, distractions with food/coffee, the integration of activities to alleviate boredom and increase stimulation, and the provision of music in Harry s room. Of further benefit would be a review of all medications with considerations for change, and the sensitizing of staff to medication complications/risks associated to the geriatric population; and, the use of consistent approaches that appeal to Harry; You ll feel better if or You ll sleep better if. Harry s medications were changed, incidences of physical and chemical restraint have been withdrawn and staff in the home began charting his behaviours to help identify triggers and respond with appropriate interventions. 9

10 BSO Project funding renewal CRO is negotiating with MOHLTC to extend the current terms of BSO Project funding to March 31, 2013, and to define a new mandate for the project after that. NSM LHIN will ensure no disruption to the day-to-day operation of CRO in the meantime. Sustainability Plans Renewed Ministry funding for BSO will include a requirement that all complete a formal Sustainability Plan, including local priorities for service improvement, organization and accountability. CEO-signed Plans will describe steps to make enhanced behavioural supports a permanent feature of the health system s normal business in your LHIN. CRO will distribute templates, timelines and detailed instructions to 14 LHIN Project Leads on Tuesday, December 18. Primary Care next steps BSO s in-person knowledge exchange event on November 15 identified leading practices and critical service gaps for community-dwelling clients. Several objectives were identified specifically in the primary care sector and a small group of will attempt to make these changes first with help from CRO, the Alzheimer Knowledge Exchange and the Provincial Resource Team. Other are likely to follow the leaders when the timing is right for them; lessons and leading practices that emerge will be available to all through BSO s collaboration infrastructure. HOPE Since June 2012, the Behavioural Support Services Mobile Support Teams (BSS-MSTs) in the Central LHIN have assisted over 500 clients and caregivers. One such client, Pauline, is a 68-year-old resident in long-term care who, over the years, has made several attempts to take her own life. This behaviour has escalated over the past year; three such attempts in a very short period of time. As a result, Paulina was referred to the Psychogeriatric Outreach Services at Ontario Shores and, following an initial assessment, was subsequently referred to the BSS-MSTs. During the course of their visits, Pauline was eventually able to open up to the BSS-MST Personal Support Worker who sat, listened and learned. The team was able to develop a plan for the future, for when those same feelings begin to resurface. Religion and hope also played a huge part in Pauline s care plan, said Debra Walko, BSS Lead at LOFT Community Services. Pauline is also blind and now wears a bracelet given to her by the team that reads HOPE. It provides comfort and helps to remind her there are so many people who care about her. Pauline and the BSS-MST team also established a non-suicide agreement on a recordable frame and using her own voice and words to express how she feels at those dark or, as she calls them horrible times. This resource also allows her to hear her own voice encouraging herself on how to move past it. Taking into account her beliefs about going to heaven and religious views on suicide, and using HOPE as the pathway to increase her feelings of self-worth and value, the team was able to give Pauline a way to express herself. At the end of the day her own strength is what carried her through, said Walko. She just needed a little guidance to see things in a new way. 10

11 Waterloo Wellington by the numbers New ways of serving residents with responsive behaviours are starting to become the norm in Long Term Care homes across the WW LHIN. An important part of successfully managing this shift to a new normal is the development of the data tools which will help staff to identify when a change is an improvement and to demonstrate successes to their colleagues so we can continue to learn and to improve the quality of care. Resident outcome indicators and process indicators being tracked by BSO teams in the 35 homes are being shared with their system partners and are directing the sustainability and spread of the initiative. 818 total number of residents followed by BSO teams in LTC in the year to date. 11 the percent of all LTC residents active on BSO caseload in Q3. 81 the average percent reduction in observed behaviours for residents discharged from BSO caseload in Q3. 38 the number of mental health transfers to hospital from LTC - Q1/Q2, 2011/12 i.e., pre-bso. & 14 the number of mental health transfers to hospital from LTC - Q1/Q2, 2012/13 i.e., post-bso. 778 the number of knowledge transfer sessions held by BSO teams (including 1:1 coaching) with LTC staff in Q the number of Quality Improvement ideas tested by BSO teams in Q LHIN action plans Final, CEO-signed Action Plans are available on LHIN websites or through as follows: Central Central East Central West Champlain Erie St. Clair Hamilton Niagara Haldimand Brant Mississauga Halton LHIN Action Plan Revisions Erie St. Clair adjusted its implementation approach to adopt a form of the hub and spoke model developed in other. A portion of the PSWs and Nursing FTEs will be allocated across the LTC homes in the LHIN catchment area. This change occurred after the LHIN was unable to reach agreement with the named service provider in the Action Plan and in order to address union issues. The change in their implementation model has resulted in recruitment delays of Nurses and PSWs and mitigation strategies to deal with the hiring of the positions. Recruitment is underway. See Section for more details. South West has changed their implementation approach from the Mobile team Lead/host Model, to the decentralized staffing model. Their proposed innovative BSO secondment model, while initially endorsed by the long-term care homes after extensive consultation, received too few responses from those same homes during an expression of interest process in Summer The revised model adopts the same approach as in neighboring Waterloo Wellington LHIN, allocating funds for Nurses and PSWs at the individual longterm care home level. In late November, South West received necessary approvals to amend their Action Plan and realign funding from both the LHIN Board of Directors and BSO s Provincial Resources Team. Because their implementation model changed, Nurse and PSW recruitment is delayed and mitigation strategies are in place for prompt hiring. Large scale recruitment is now underway. See Section for more details. Implementation Adjustments North East North Simcoe Muskoka North West South East Part A Part B South West Part A Part B Toronto Central Waterloo Wellington Two additional, South East and Waterloo Wellington, identified implementation adjustments in Q3. Both have met their HHR targets. Changes identified below have not affected their overall recruitment efforts. Waterloo Wellington (WW) While targeted in the action plan, WW was unsuccessful in recruiting an Advanced Practice Nurse (1.0 FTE). However, further review of Community Behavioural Support Service referrals indicated a need for enhanced community social work and part-time enhanced Psychogeriatric Resource Consultant services. 11

12 As a result, WW opted to recruit 1.0 Social Worker and 0.4 PRC-Community in late November. Overall recruitment was completed in December South East (SE) - SE adjusted implementation activities to further manage change, support a focus on person-centred care, align leadership structures with a chronic care approach, and to appropriately define target population boundaries. Specifically, SE included access to BSO Connect (24/7 integrated coverage) reviewed staffing complements and incorporated changes to enhance recruitment and retention of staff dedicated one point of service to regional intake and triage services leveraged Best Practices in Primary Care focusing on an integrated approach using best practices and a Canadian Institution of Health Research grant: Primary Care Dementia Assessment and Treatment Algorithm Implemented a process for performance reviews to ensure that Providence Care receives continuous feedback on the service delivery model and its effectiveness Continued to engage leaders from long term care homes, CCAC, mental health & addictions to ensure SE service meets the needs of both the target population and community partners Revised the Psychogeriatric Resource Consultant role to increase cross sector involvement and be used as a capacity development resource for other specialty services and their partners Provincial Resource Team (PRT) During Q3 the PRT continued with their mandate to surface promising practices, identify and address broad challenges and connect to timely and relevant information; to inform local implementation. In addition, the PRT provided episodic project advice to inform the integrated success and sustainability of BSO. Surface Promising Practices Process: During Q3 the PRT aimed to surface local promising practices so other could learn from and build on the success of others. Due to the success of the first round of LHIN-PRT exchanges (completed mid-summer), and the positive feedback from both and PRT members, a second round of exchanges occurred from September-December These exchanges offered an opportunity for PRT members to respond to promising practices, suggest additional considerations and recommend new partnerships to explore. Examples: Promising practices shared in Q3 included Person-centred resources Technology-enabled service delivery Local BSO learning and development networks Engagement of new stakeholders (e.g. GEM nurses) Service team integration. Turnaround Dementia, compounded by a frontal lobe tumor, was not the diagnosis Mr. Richards and his family expected to receive. Inappropriate outbursts, displays of violence and threats to harm himself and others were truly undesirable and uncharacteristic behaviours that affected everyone around him, including family, fellow residents and staff at Dufferin Oaks Nursing Home in the Central West LHIN. Managed initially through one-to-one care, Mr. Richards required a disproportionate share of resources and exhausted staff on a daily basis, as they made every attempt to manage and predict his behaviour pattern. Regular visits and assessments to the psychogeriatric clinic, complex case review, care planning to address medication use/ approach to care and staff education were all considered essential elements of a person-centred care plan designed to turn Mr. Richards around, and transform him back to his former pleasant, cooperative and caring self. Equally important, would be the engagement of a family who was both embarrassed by his behaviours and unwilling to acknowledge and/or deal with their existence. Over a three month period, a reduction in episodes and elimination of intense verbal encounters was noted; a turnaround that has sustained itself to date. With tools and resources in place, there is no longer the presentation of agitation, high-intensity resources are no longer required, staff members are at ease when caring for Mr. Richards and his family is once again visiting regularly. I have to commend all staff for their hard work, said Tina Cadorette, BSO Champion. Mr. Richards was definitely a challenge and staff needed to have the right tools to understand the approaches and getting familiar with the resident. I needed support from my PRC, co-workers and leadership to grow with this experience. Over the last quarter, this LTC home has successfully reduced episodes of responsive behaviours from 215 to 92, down 57%. More complex case reviews are completed every month, resulting in a 50% increase in responsive behaviour management. Less obvious and not so easily measured is the reduction in triggers to other residents within the home and much higher staff satisfaction. 12

13 Dominoes In the Central East LHIN, focused teamwork and Montessori activities have led to improved quality of life and reduced responsive behaviours for a resident at Bendale Acres. Cecil is a 67-year-old retired teacher. He is married with 2 children. He has been diagnosed with dementia, Parkinson s, hypertension, COPD, diabetes and depression. He has had a knee replacement and last summer experienced a fall that necessitated a hip replacement. Since returning from hip surgery, Cecil has demonstrated a variety of responsive behaviours including increased agitation, restlessness, confusion, bouts of screaming for help, attempting to leave his wheelchair and frequent verbal aggression toward staff and other residents. Referred to and assessed by the BSO team, these behaviours were observed to occur primarily during afternoons and evenings. Prior to BSO involvement, Cecil s care plan involved medications for both pain and anxiety. Focusing on a person-centred care plan, the BSO team began interventions in August of last year. Having developed a comprehensive understanding of Cecil s interests and social history (relationships past and present), the BSO team determined his current optimal level of functioning and, with his involvement/agreement, established realistic activity goals. The result was a person-centred program of interventions and activities to optimize Cecil s cognitive, social and physical function. Montessori activities were introduced and he readily accepted, including reading, listening to stories and small group activities like bowling, dominoes and karaoke. A recent evaluation shows a drastic reduction in Cecil s responsive behaviours. He has not fallen in the past three months, is more co-operative, enjoys and looks forward to participating in activities on and off his unit, spends longer visits with his wife and interacts more frequently with fellow residents. Staff are spending less time managing Cecil s (less frequent) behaviours and there has been a noted decrease in the use of medication to manage them as well. Address Challenges Process: During each LHIN update to the PRT, Leads were encouraged to bring forward any emerging issues the PRT may be able to assist with. PRT members responded to these issues by taking into consideration local contextual elements and suggesting resources, processes or new partnerships for consideration. Throughout this process, the PRT recognized that some challenges were being identified by multiple 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. Example: Primary care engagement Through updates to PRT and a focused conversation at the BSO knowledge exchange event in November, it was evident that primary care engagement was a hot topic for. However, what was also clear is that each LHIN was at different stages and using various strategies to partner with family physicians. Through ongoing exchange, PRT identified multiple considerations to inform this partnership process. In December the PRT hosted a conversation with LHIN leads to discuss strategies and support needed to connect action at a provincial level. Anticipated Outcome: PRT, in partnership with AKE, is now working on developing a checklist of key recommendations and considerations to guide primary care engagement at a LHIN level. This checklist will be shared with in Q4 to support engagement and enable to identify keys to success and lessons learned along the way. Connect 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 publish the PRT Update to LHIN Leads following each meeting. These updates connect to practical, timely and relevant information to inform implementation. Where other knowledge dissemination processes in the project focus on broad project messaging, this focuses more precisely on considerations to immediately improve system coordination, service delivery and capacity building at the local level. Each PRT Update includes : A highlight of 2-3 promising practices or provincially relevant areas of discussion Tips & Tricks from PRT (e.g. practical strategies to consider during implementation) Links to resources shared during PRT meetings. Episodic Project Advice In addition, PRT has provided invaluable strategic direction and recommendations on BSO provincial topics, including but not limited to: BSO Capacity building suite of tools LHIN sustainability plan templates and recommended processes for completion Strategic partnership opportunities with Bruyere Centre of Learning, Research and Innovation in Long Term Care Medication and Safety BSO for community-based clients. 13

14 1.3.5 Knowledge exchange In Q3, the Alzheimer Knowledge Exchange (AKE) supported knowledge exchange activities across the BSO project as follows. Support existing and newly hired health service providers to develop core competencies and to refine and apply practice models emerging from the BSO project Conducted a survey with the BSO Capacity Building Community of Practice (CoP) to better understand local and provincial BSO capacity building activities and needs related to connecting with others across the province who are involved in capacity building activities. Spread awareness about BSO Capacity Building tools, in particular The Road Ahead to support individuals, teams or organizations in their continual development of the 12 BSO recommended Core Competencies. The tool # describes a selection of strategies to support learning to enable decision-making about how, why and with whom they plan their continued capacity building. Efforts included 2 online knowledge dissemination sessions that highlighted the tools in the AKE Resource Centre, and inclusion of the tool in the AKE newsletter. Build the capacity of families to effectively participate in the care of persons experiencing responsive behaviours Began visioning for and plans to, create a Family Toolkit that will support the development of knowledge and skills related to responsive behaviours for families of those living in long-term care. Specifically, the toolkit is intended to: - Increase the care partner s awareness and understanding of responsive behaviours, triggers and the common issues related to responsive behaviours in a long term care setting. - Assist the care partners in understanding how these behaviours relate to their family member s day to day functioning in the LTC home. - Provide strategies to the care partners for meaningful interaction with their family member and ways to support the resident in a LTC home. - Emphasize the care partner s value in the care of the person diagnosed. - Decrease any guilt or shame the care partner may experience, in association with the responsive behaviours displayed by their family member. Also explain that the behaviour is not the fault of the care partner. - Provide skills, tips and strategies for care partners to engage and communicate with LTCH staff on care issues (adhering to privacy legislation). It s All in the Delivery In Q3, during the Champlain LHIN s BSO implementation phase, significant resources have were devoted to building capacity of the Champlain Behavioural Support System (BSS) workforce. Notably, BSS resources were used to deliver an intensive LHIN-wide training program, tailored to the needs of the new role of Personal Support Worker Champion. Upwards of 1,400 hours of training were delivered to a group of 100 Champions. The two day program provided new knowledge and hands on experience for Champions to learn new skills and connect with the outreach behavioural support nurses they collaborate with, when providing person-centred care for those with behavioural needs. Additional training, designed to have the Champions learn from each other, will be carried out in Q4. Also of note, Champlain behavioural support resources were utilized to free up 16 behavioural support Residents First teams, in order for those teams to develop quality improvement plans. The net result was an enhanced focus on behavioural needs and the development of quality improvement plans that will drive further Champlain BSS change. The toolkit will be developed using a combination of research and practicebased evidence, as well as lived experience. This work is anticipated to be completed and made available in Q4. 14

15 Identify and disseminate best practice concepts, tools and resources Planned and hosted a BSO Knowledge Exchange online session Shared Stories: Enhancing Knowledge and Building Capacity to Provide Better Care to Support Older Persons with Responsive Behaviours on October 31, Two different BSO innovations in LTCH capacity building were highlighted. 220 people attended. Highlighted BSO updates in the AKE newsletter with a distribution of more than 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 and others implementing BSO locally. Provide Knowledge Transfer and Exchange (KTE) support to BSO Collaboratives Worked with the BSU Collaborative toward approval of all proposed units and a standardized inpatient and outpatient satisfaction survey to be applied to all BSUs. Facilitated Mobile Team development and trialing of standardized metrics. Supported the BSU, Mobile Teams and Centralized Intake Collaborative working groups to begin visioning in order to determine short, mid and long-term goals and requirements for sustainability including membership and leadership structures for these groups as current leads transition to new roles. Supported an in-person meeting of the Centralized Intake Collaborative. As part of the re-visioning process, this group was renamed the Enhanced Access and Flow Collaborative to better reflect goals of accessibility, smooth transitions which may include centralized intake processes and system navigation. A meeting of regional BSO implementation leads is also planned to follow the meeting. This will help regional leads for BSO begin Initiated a BSO Operations Table consisting of those who are actively involved in the planning and implementation of BSO activities at a local level to develop a common identity and explore their collective needs for collaborating together. This leadership group will carry on the momentum of BSO in the field on an ongoing basis. The group met for the first time on Nov. 15 th in person. They discussed goals for the group and how to move forward together. The AKE will provide Knowledge Broker and technological support to the group. A needs assessment to gather information about roles of individual members, successes and challenges to support goal setting for the group was implemented. Hi Jackie February 2013 will be Mobile Response Team Appreciation Month at Crown Ridge Place in the South East LHIN!! submitted courtesy: Sandra Redner, Administrator Crown Ridge Place We would like to designate February as Mobile Response Team Appreciation Month. We designate different months of the year to honour our different classifications of staff and one of our RPNs suggested doing one for MRT as your team has been so helpful to us. We would like to show our appreciation. We would like to schedule one day to bring in pizza for all of your team members. Please let me know what day in February that you could possibly have most or all of your team members in for a luncheon, we could also order on evenings, if some could come later in the day. Also I was wondering if you would be available on February 19th to review your team s role and discuss how our staff can support (perhaps better support) your team s role, at our mandatory staff education session in the afternoon. Thank you so much for everything, you and your team have been just amazing! We appreciate it. 15

16 BSO and Community Spread Many health and social service providers intersect to provide support for persons with responsive behaviours and their families within their home and during their journey through the health care system. The Behavioural Supports Ontario project has set out to build a health system that has an integrated service delivery, coordination and management and a knowledgeable care team based on capacity building focused on older persons with challenging behaviours due to cognitive impairments and their families. Health service providers in the community must be invested in as they are leaders across regions and are vital to the sustainability of behavioural supports. A knowledge exchange event was held on November 15, 2012 providing an opportunity for key stakeholders from across the province to come together, some for the first time, to determine/develop ways in which behavioural support innovations can be realized and supported at the community level. Having brought together a total of 67 participants, this event was a true collaboration between sectors, organizations and. Those who took part felt the exchange enabled them to better understand what others are doing; identify challenges and linkages, opportunities for new knowledge to enable them in their own area; and identify next steps as a group for collaborative action BSO impact assessment evaluation Third quarter activity for the BSO evaluation project focused on obtaining an in-depth understanding of BSO s impact on health care providers as well as a greater knowledge of the lived experience of those receiving BSO services. In addition, quantitative measures of BSO impact were refined. During bimonthly meetings with the Data Measurement and Evaluation Committee (DMEC), all indicators/measures/tables were reviewed in detail to determine their utility in the final evaluation report. Once the indicators and the tables for the final report were identified, activity focused on submitting data requests and obtaining approvals from the Ministry s IntelliHealth data archive. Although 2011/12 administrative data, data that were to be used to establish the pre-implementation baseline impact of those living with responsive behaviours, was available and provided to the consultants (with the exception of the data from complex continuing care facilities, which will be provided early in Q4), during these data negotiations it became apparent that 2012/2013 Q1 and Q2 data, data that would be needed to show system level impacts following the implementation of BSO strategies in Q4 2011/12 and Q1 2012/13, would not be available until the end of January Although the formal evaluation contract with HayGroup finished at the end of December 2012, the consultants have agreed to defer the submission of their final report until the end of February, by which time the data from 2012/13 Q1 and Q2 will be available. It is expected that a draft report summarizing the quantitative impacts of BSO will be sent to the DMEC for review in February As many of the BSO initiatives in Early Adopter were focused in a subset of LTCHs, the DMEC recommended that the quantitative analysis isolate and assess the measureable impacts on the clients in these LTCHs, as well as LHIN-wide impacts. Understanding the BSO experience through the eyes of key stakeholders was identified as being key to the evaluation. Working in collaboration with the four Early Adaptor, the HayGroup developed strategies that would generate a greater understanding of the impact of BSO-related changes in system capacity and access to care. Survey instruments (both paper and online links) were provided to LHIN staff, who coordinated the distribution to identified health care providers within their LHIN. 16

17 1259 surveys were distributed to service providers and 249 were returned, for a survey response rate of 19.8%. Survey distribution rates and response rates varied substantially among the 4. In addition, information on the lived experience of someone who received BSO services was obtained through focus groups. Fourth quarter DMEC activities will focus on: receipt and review of the HayGroup BSO evaluation report; examination and endorsement of a short list (8-12) of Legacy performance measures/indicators that will be used to assess long-term BSO health system impacts and to guide a LHIN s BSO sustainability planning; and development of a dissemination strategy for findings of the BSO Evaluation report. Also in Q4, the CRO and the Early Adopter will be responsible for confirming that the HayGroup has completed the work they were contracted to do for the BSO evaluation. As well, the HayGroup will continue to respond to requests for clarification or technical questions as needed after their submission of the full final report in Q4 within the terms of their contract Sustainability planning With input from the BSO Coordinating & Reporting Office and the Provincial Resource Team, the project developed and shared with a process and template to guide LHIN-level sustainability planning. will complete the template in Q4. Some already have highly developed strategies and good infrastructure to maintain the project s momentum in the long-term. For these the template is an opportunity to compile what they already know in a single public document. For others this is a structured opportunity for systematic discussion about their newly enhanced system of local behavioural supports. The proposed process for completion of LHIN Sustainability Plans will include: LHIN-wide consultation with service providers, behavioural supports stakeholders and people with lived experience; provincial knowledge exchange (both in-person and online); review by CRO and PRT; LHIN CEO approval; posting online. Give Me a Sign The introduction of a Community Support Worker to the Acclaim adult day program in Oakville, allows new strategies to reduce exit-seeking at an adult day program, and avoid disruptive behaviours with other clients of the program as well. In the Mississauga Halton LHIN, Charlie attempted to leave on his own every single day he participated in an adult day program. He would continuously approach the exit, wait and try to leave when others would open the door. He would also stand by the door and block others from using it. This behaviour, coupled with his interactions with staff who tried to stop him, disrupted other program participants. Attempts to engage Charlie in activities directly after lunch were only effective for several days, after which he continued to try to leave the program or refused to participate. Staff held a behaviour huddle to discuss the situation, and they decided to place a sign at the door. The sign read Attention: Staff and Students. No persons shall stand by this door. Emergency Exit. The first day seeing and reading the sign, Charlie turned around and returned to the program area. He has also been seen telling other clients about the sign and that they should not block the door. With exit seeking and disruptive behaviours reduced, staff report a positive impact on Charlie, staff and program participants. 17

18 Chapter 2 quantitative 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 insight into 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. 2.1 Investment in HHR The MOHLTC s $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, (See Behavioural Supports Ontario Q4- Quarterly Report January 1,2012 March 31,2012. Section 2.3 HHR Investment pp 20 29) 18

19 Seeing is Believing Sometimes seeing is believing. Doubtful they could make a difference in in the life of a person who, with progressive responsive behaviours, had already been attended to by several other service providers, the Mobile Support Team (MST) in the North Simcoe Muskoka Local Health Integration Network (NSM LHIN) pressed forward hopeful that even the slightest of positive results could be achieved. Gordon, a resident at Georgine Manor in Penetanguishene, has progressive dementia and was confined to a wheelchair. Realizing there existed an opportunity to improve his quality of life by providing him with some degree of freedom and independence, the team implemented a walking program to improve his mobility. With new tools and resources to navigate the process, the team felt better equipped for a successful outcome, where previous attempts had failed due to increased behaviours and physical aggression. The MST initiated a walking program with clear parameters and the overall goal of allowing Gordon to complete a daily controlled walk. Gordon s behaviours were tracked using the Dementia Observation System (DOS) assessment tool which collects data and identifies the average numbers of behaviours occurring each day. Prior to commencing the walking program, Gordon demonstrated an average of 12 aggressive behaviours per day. Through implementation of a successful walking program, those same behaviours are down to an average of 5. Sometimes seeing really is the only way to believe in yourself, your team, your client, said Haley Row, RPN and member of the NSM MST team. Seeing Gordon succeed, when all other attempts had failed, was enough to inspire and motivate the LTC home staff to believe in the walking program, our MST to believe in themselves, and Gordon (and his family) to believe in himself. Amazing results can be achieved in the most unexpected situations HHR hires During Q3, continued to support local Health Service Providers to ensure the best possible BSO staff are recruited for this initiative. As of December 31, 2012, a total of 523 FTEs had been recruited provincewide, up from 495 FTEs reported at the end of September 2012 for the previous Quarterly Report to MOHLTC. 9 were fully recruited by yearend; detailed information about FTE commitments and new hires in each LHIN is recorded in Table on page 20 of this report. The total projected FTE count is now estimated at 583 which is up slightly from the previous estimate of 580 in the previous quarter. This adjustment reflects the change in type of professionals hired in the Other Health Professional category which allowed for more professionals within the available funds Recruitment strategies and tools In the Q4 Report 2011/12, a number of strategies and tools were outlined by the HHR Committee to assist with their recruitment efforts. This included the following: Development of 12 Core Competencies Standardized Job Descriptions and Job Postings Standardized competency based interview questions Review and sharing of Memoranda of Understanding between the LHIN and HSPs and between agencies Targeted online advertising to support recruitment. These tools supported LHIN recruitment of the right people to provide services to BSO s target population. Subsequently, in Q1/Q2 of 2012/13, the project released three resources to support capacity building: The BSO Capacity Building Roadmap The Behavioural Education Training and Supports Inventory (BETSI) Person and Practice Based Learning tool (PerPLe). During Q3, BSO launched its fourth project-wide resource for staff learning and development, The Road Ahead. Designed to support continuous learning at any point in a caregiver s career, The Road Ahead complements the aforementioned resources above, and completes the now known BSO Capacity Building Suite. Further information regarding the Capacity Building Suite can be found in Section of this report PSW Funding received additional base PSW funding on December 20, 2012 to support the recruitment and retention of PSWs as an integral part of the BSO initiative. These funds were given in recognition of current salaries for PSWs and the need to increase funding to enable to meet their original PSW targets. Accountability agreements between the MOHLTC and for the New Behavioural Staffing Resources have been amended to include this funding. Once meet their FTE targets, the remaining funding, if any, can be used to train LTC staff (nurses, PSWs and/or additional LTC healthcare providers) in LTC Homes. CRO is working with the to roll out these funds as quickly as possible and will optimize the staffing mix based on local circumstances and FTE targets. 19

20 Action Plan FTE Commitments Hired as of December 31, 1012 Nurse PSW Nurse PSW LHIN FTEs FTEs FTEs FTEs (LTC (LTC Add'l Total FTE (LTC (LTC Add'l only) only) FTE Commitment only) only) FTE Total Erie St. Clair South West * Waterloo Wellington * Hamilton Niagara Haldimand Brant * Central West Mississauga Halton * Toronto Central Central ,38 Central East * South East * Champlain * North Simcoe Muskoka * North East * North West TOTALS Note: Shading denotes Early Adopter * Note: All staff are hired in these positions as of December 31, Turnover and attrition may occur in any one position after this date and will not be reflected here. Table BSO FTE Hires and Staff Trained (as at December 31, 2012) 2.2 Activity Tracking agreed to standardized definitions of their major BSO investments to better reveal trends and common approaches across LHIN boundaries. A first set of indicators were also selected, to be expanded and enhanced in future reporting cycles. A picture of projectwide resource deployment and relative priorities begin to emerge. Agreed nomenclature and definitions that apply in all are a crucial first step toward an accurate tally of BSO services by type and function. In future, reliable province-wide counts for a wider range of BSO initiatives will facilitate impact assessment, cost comparison and projections of return on investment. 20

21 A note about LHIN-LHIN comparison using Activity Tracking data: LHIN-LHIN data differences most often result from differences in the local service model, target population and complementary service mix. Although some will compare their performance with known peers delivering similar services, casual observations about relative LHIN performance are misleading because this context is obscured. Initiatives and Investments Mobile team (I) - Lead/Host Model A lead organization recruits, trains and delivers interdisciplinary outreach support in care settings throughout a region. Usually the lead is an LTC Home delivering care to residents in other homes subject to terms in a formal MOU. Support is scheduled or episodic, and includes skill-building mechanisms for other staff and family in the patient's or resident's circle of care. Totals Q1 8 Totals Q2 7 Totals Q3 6 ESC SW WW HNHB MH CW TC Central CE SE NSM Champlain NE NW X X X X X X # staff hired (cumulative FTEs) # client contacts 1507 Total # of referrals to the mobile team Total # of clients, families the mobile team provided support to Time from call to first response from Mobile Team <24hrs 120 <24hrs % of referrals with a follow-up discussion between the mobile team and the referring % 100% 100% 100% organization/individual # of client-based services delivered Client-based services where follow-up and review of outcomes occur # of provider based services delivered (case consultations, huddles, skill building, etc) # of service improvement activities completed (VSM, PDSA, new algoriths, etc) Mobile Teams in Central and HNHB accelerated direct care to clients in Q3. They collaborated with LTCH staff, caregivers in the community and the clients themselves, on creative approaches to reduce challenging behaviours. Team members modeled care plans for LTCH staff and caregivers to follow, and they improved residents quality of life. Teams in the two delivered initial and followup care 8157 times during this reporting period, accounting for three-quarters of the provincial total. They added 1073 and 858 case consultations, respectively, ensuring BSO expertise transferred to others in the clients circle of care. The SE LHIN Mobile Response Team had an average response time of hrs., following first call for service. The SE LHIN, guided by continuous improvement, continues to mine their data in an effort to understand how external factors (geographical disparities, dates/times) impact service delivery. Understanding contextual factors helps SE teams to reassess targets for improvement, and to implement efficient, person-centered care. Recruitment concluded for mobile teams based in Thunder Bay and Kenora. Teams began accepting referrals on November

22 Initiatives and Investments Mobile team (II) - Decentralized Staffing Model On-site nurses or PSWs dedicated to behavioural issues in a LTC Home. This model is common where existing mobile interdisciplinary resources are already available to some or all of the participating LTCH. In some the Homes that receive BSOfunded staff assume team leadership duties for a cluster of other LTCHs nearby. Totals Q1 4 Totals Q2 6 Totals Q3 7 ESC SW WW HNHB MH CW TC Central CE SE NSM Champlain NE NW X X X X X X X # staff hired (cumulative FTEs) # client contacts 696 Total # of referrals to the mobile team Total # of clients, families the mobile team provided support to Time from call to first response from Mobile Team N/A % of referrals with a follow-up discussion between the mobile team and the referring % 100% organization/individual # of client-based services delivered Client-based services where follow-up and review of outcomes occur # of provider based services delivered (case # of service improvement activities completed (VSM, PDSA, new algoriths, etc) Capacity enhancement training program Comprehensive behaviours training strategy for new and existing staff in LTC, Community and acute sectors X X X X X X X X X X X X X # participants in structured learning events Using a decentralized staffing model for Mobile Teams, the WW LHIN delivered 1088 provider based services in Q3 including team huddles, coaching on resident- / client- specific behavior management plans, case-based learning, one-on-one coaching, formal education and skills building. These activities have enhanced the capacity of providers across the system to understand and respond to the needs of individuals with responsive behaviours. They also provided a common clinical knowledge framework and quality improvement language, thereby improving collaboration, integration and transitions across the continuum the number of staff who participated in structured learning events across the SW LHIN; providing an opportunity for staff to enhance their skills and consider ways in which new knowledge could be adapted and applied within their own practice. environments. Participation in P.I.E.C.E.S., UFirst!, GPA, mental health & addictions and other training events leapt to 3342 in the third quarter. This three-month total is the highest recorded, and doubled Central West s performance in Q the number of referrals received by the Champlain LHIN Mobile Team; on-site behavioural staff are being recognized and utilized to provide additional support when complex responsive behaviours are present. 100% the percentage of follow-up discussion carried out between the Champlain LHIN Mobile Team and referring organization / individual; enables a consistent approach to care, collaborative solution finding and spread of new skills. 22

23 Initiatives and Investments Other mobile or regional specialist roles PRCs, geriatricians, psycho-geriatricians and others intended to augment existing local teams or serve as a specialist resource for the existing service mix in the LHIN. Totals Q1 12 Totals Q2 12 Totals Q3 12 ESC SW WW HNHB MH CW TC Central CE SE NSM Champlain NE NW X X X X X X X X X X X X # staff hired (cumulative FTEs) # clients served Behaviour Support Champions in LTC Specialized role on staff at a long-term care home responsible to lead, coordinate and spread effective strategies for responsive behaviours in that facility X X X X X # staff hired (cumulative FTEs) # clients served BSU Transitional specialized support for persons whose responsive behaviours have become unmanageable in their current setting and for whom available supports have not been successful in management of the behaviours of concern. The goal of the unit is to stabilize behaviours and support transition until residents return to their home, which may be in another long-term care home or in the community. The unit provides a higher level support model than is currently available in other LTC homes. Length of stay parameters are set by each individual BSU based on resources available X X X X X # staff hired (cumulative FTEs) # clients served 32 # of Referrals # of Admissions # Discharges Mean LOS Clinical (days) Mean LOS ALC (days) 86 0 n/a 0 0 Geriatric Mental Health Outreach Teams saw 243 clients in the third quarter. In ESC LHIN, these teams focus on high-intensity residents to free BSO mobile teams for a larger volume of low- and mediumintensity clients. The CW LHIN finished BSO recruiting this Fall. BSO champions increased familiarity with their roles and responsibilities to serve 2945 clients, a 60% increase since the last reporting period. MH LHIN Behavioural Support Unit saw a decreased mean length of stay from 420 days in Q2 to 226 days in Q3, thereby meeting their clinical goals; receiving the right care in the right place, in a timely fashion, is beneficial for existing and outgoing patients and incoming people who are waiting for services. 7 the number of people admitted to the MS LHIN Behavioural Support Unit at Sheridan Villa. The Behavioural Support Unit provided a higher level of support and enabled behaviours to be stabilized before residents return to their home setting. The TC LHIN s new Behavioural Support Unit at Baycrest began receiving referrals in October. Of 21 referrals this Fall, most are from hospitals and the community. In September, the Central LHIN s Cummer Lodge gained 8 beds as a Ministry-designated Special Behavioural Supports Unit. Long-stay residents living with Huntington s disease were already receiving specialized care for responsive behaviours at Cummer Lodge which explains a mean Clinical Length of Stay of 738 days that predates the unit s designation in the Fall. 23

24 Initiatives and Investments Centralized access (One-number-to-call) Centralized access to the BSO Mobile Support Teams and other behavioural support services through one number, including risk screening, triage and referral to other appropriate services Totals Q1 6 Totals Q2 7 Totals Q3 7 ESC SW WW HNHB MH CW TC Central CE SE NSM Champlain NE NW X X X X X X X # calls meeting criteria for BSO teams/services # calls to intake from community # calls to intake from LTC # calls navigated to another service System Navigator Dedicated coordinator responsible to plan appropriate complementary services throughout a patient's journey. Includes centralized access to BSO resources (incl. Mobile Support Teams). Could include short-term support by Intensive Geriatric Services Worker until one or more referrals is complete. Common assessment toolkit Development of a common minimum set of assessments (standardized assessments) for people with responsive behaviours across the service continuum. The toolkit outlines the service events, process steps, common assessment tools and pathways. The local Mobile Support Team will provide education to service providers on the use of the toolkit, interpretation and application of the tools and pathways X X X X # clients served X X X X X # clients assessed System Navigators in Erie St. Clair gained experience and momentum, increasing their clients served six-fold since the previous quarter. Community service providers and LTC homes referred 66 people through the NSM LHIN s centralized access point for behavioural supports; two-thirds of them communitydwelling clients. This share is likely to increase when BSS access through is promoted to the public beginning in Spring In the NE LHIN 59 calls were received through a centralized access number that met the criteria for BSO services. While it is clear that the community is recognizing this as a natural point of entry to access and connect to BSO services, development of a revised mechanism and tracking tool, for all BSO funded Health Services providers to use, will facilitate this type of data collection consistent with the indicators going forward. 24

25 Initiatives and Investments Integrated Care Team Redesign of existing resources in community and/or LTC (including NPSTAT, PRCs, GAIN, CCAC, hospital, community mental health, etc) to ensure collaboration and seamless care transitions. Totals Q1 6 Totals Q2 8 Totals Q3 8 ESC SW WW HNHB MH CW TC Central CE SE NSM Champlain NE NW X X X X X X X X # participating organizations # clients served Complex case resolution Forum for CCAC, CSS, primary care, Alzheimer societies and others to discuss shared clients (older adults in community with responsive behaviours) whose multiple complex needs require a coordinated response X X X X X # of participating organizations # clients served Primary care toolkit New toolkit containing assessment and screening tools for early identification and management of individuals with responsive behaviours X X X # primary care physicians used the toolkit # clients assessed New tools, clinical pathways, value stream maps System redesign efforts to realign, optimize or better integrate the existing local service mix. Examples include order sets, GMHOT, and SBAR/Huddle X X X X X X X X X X X X X X number of new tool/toolkit/pathway number of tests of change in this quarter (to be completed by IF) The WW LHIN has nurtured and deepened system partnerships, enabling 107 organizations to collaboratively provide integrated care and seamless transitions for the client and family. These collaborating organizations cross long term care, specialized geriatric services, primary care, memory clinics, Adult Day Programs, Emergency Departments (specifically Geriatric Emergency Management Nurses), Acute Care, Nurse Led Outreach, Psychogeriatric Resource Consultants, Long Term Care, Community Support Services and CCAC. In the HNHB LHIN, 198 people living at risk in the community were served through the BSO Community Outreach Team. This service enabled the clients to be supported through their crises, stabilizing their situation through assessments or referrals to services, and most importantly, linking them to longer-term supports of a lead agency (Integrated Community Lead) to reduce future crises. The HNHB LHIN created 16 new resources in Q3; hosting and recording 12 education sessions via OTN to foster a culture of continuous learning and exchange. Led by Dr. Dallas Seitz, funded by a Canadian Institutes of Health Research Knowledge to Action Grant and in partnership with Providence Care, Queen's University and Behavioral Supports Ontario, the Primary Care Dementia Assessment and Treatment Algorithm (PC-Data) tool has been introduced into several primary care settings. 24 physicians have used the tool on 14 assessments. NE and CE led all in the application of QI techniques to BSO service redesign. New approaches to care and new tools, pathways and maps reflect a methodical stepwise transformation at the clinical frontline. The NE LHIN engaged 18 new partner organizations (for a total of 26) to support the collaborative review of 35 cases, evidence that NE health service providers are committed to sharing accountability and improving care and services for their complex clients. 25

26 Initiatives and Investments Online behavioural supports portal Online compendium of local behavioural supports resources. Includes self-assessment tools and contact information. launch date Totals Q1 3 Totals Q2 2 Totals Q3 2 ESC SW WW HNHB MH CW TC Central CE SE NSM Champlain NE NW X X May Sept, 2012 Visual Communication Board 'White boards' to communicate care plans in LTC 1 LHIN 2 2 total # of LTC homes planned # of LTC homes in operation BETSI X X X X X X X X X X X X X X # organizations applying the tool Roadmap X X X X X X X X X X X X X X # organizations applying the tool Presentations and outreach X X X X X X X X X X X X X X # outreach events or presentations X X Note: Former measures not currently in use Note: Ontario Average LOS not calculated The SW continues to focus efforts on activities that will generate the greatest return on investment. 85 organizations used both the BETSI tool and Capacity Building Roadmap to strategically assess and target capacity building activities that would have the greatest impact on point of care, team, organization and system transformation. South West LHIN conducted 49 outreach events or presentations, a demonstration of their commitment to engage and listen to their stakeholders, keep their community 'in the know,' and enable an integrated system of care. PRCs used a short survey based on the BETSI tool to assess staff learning needs in 36 local LTC homes and develop an appropriate education plan. BSO white boards continued to expand in Central East LTC homes, rising to 45 out of 69 planned. NSM CCAC is leading an effort to refresh and animate the BSO portal on nsmhealthline.ca. Collaboration with BSO teams in other may create an opportunity for a province-wide behavioural supports portal. The PRC team, the BSO Regional Coordinator and the Regional Geriatric Psychiatry Champion in the NE were instrumental in the development of custom made training initiatives in response to needs identified through the BETSI tool. These included a PSW Champion Course, a Geriatric Mental Health Foundations workshop and securing funds to offer Montessori, P.I.E.C.E.S. and GPA training staff participated in these structured learning events this quarter. NW has the smallest population and the largest geography of all. 64 BSO presentations at Board meetings, lunch & learns and outreach events in Q3 made NW the per capita leader among all. 26

27 2.3 Evidence of Change Spotlight on QI Data BSO emphasizes a data-driven approach to service improvements. Local project teams are trained to apply formal quality improvement techniques: they identify and prioritize problems, select and analyze the measurements that isolate the performance gap, complete trial improvements, and then spread and standardize the solutions that brought sustained improvements. By linking multiple change projects together, and tackling the root causes of larger issues, local project teams are making important progress on complex, persistent system issues. Performance data from the Mobile Response Team in South East are typical of small-scale BSO changes that add up to high quality care. Once the team began accepting referrals last summer, shorter response times emerged as an improvement priority in order to meet local demand for the new service. Chart 1 shows a short adjustment period while team members learned new roles and adjusted their processes, and then prompt service became normal week after week. Special causes pushed response times up in early December (outbreaks in several LTC homes introduced delays for infection control), but the long-run average was restored once these special causes were addressed. Chart 1 Simple statistical tests for normality and statistical significance confirm the team has completed the implementation phase. A steady state has been achieved with the current delivery model and the team s performance is predictable. This insight is crucial for planning purposes or if it becomes necessary to adjust response times to meet new system needs in the future. Different performance measures are relevant in Central East, where the BSO project team matches assessment data to LTC residents with new or escalated behaviours. Staff rely on a standardized Behavioural Assessment Tool to help them identify, understand and manage responsive behaviours. Chart 2 shows a full year of data from all long-term care homes in the LHIN. 27

28 Chart 2 About half of all residents exhibiting new or escalated behaviours were already on a care plan developed using the BAT. The rate was much higher when the tool was first introduced, but over time LTC staff adjusted its use to focus on more serious and complex situations; the resources required for assessment can be deployed elsewhere in less serious cases. Responsive behaviours are also reported more consistently and more frequently as a result of BSO, increasing the denominator. In the current reporting period staff report they have found the right balance, and the monthly rate has stabilized around the average (since August) of 49%. With reliable data and predictable performance on this indicator, the BSO project team in Central East may find it can drive other outcomes by adjusting the BAT rate up or down in future. Process measures like the ones in Charts 1 and 2 are significant when they combine with other factors to change outcomes for BSO clients. Charts 3 and 4 show BSO effects on residents behaviour using data from Pinehaven Nursing Home (Waterloo Wellington) and aggregated totals for Trillium Manor, Sunset Manor and Georgian Manor (North Simcoe Muskoka). Chart 3 Chart 4 28

29 In both, residents benefit from a range of complementary BSO services and BSO-trained staff. The indicators depicted in Charts 3 and 4 show the combined impact of the BSO transformation and some non-bso causes as well without attempting to attribute outcomes to specific interventions. HayGroup s assessment of BSO outcomes will take this analysis further when the final report is presented in Clear correlations between better care quality and BSO implementation are becoming abundant in all and across sectors of the health system. Lower incidence and severity of resident behaviours shown in Charts 3 and 4 are a necessary precursor to more complex BSO goals including better care quality and reduced costs to the system. Chart 5 shows the additive effect of many changes that combine to transform a client s care. The use of antipsychotics declined dramatically in this example from Saugeen Valley Nursing Centre (Waterloo Wellington), down from once a day to once a month. The resident, her family and staff in the home can all celebrate the difference this reduction makes for her quality of life. Chart 5 The additive effect of BSO on the broader health system will be difficult to isolate, but evidence of system change is accumulating. Chart 6 is one example, showing unplanned ED transfers from all long-term care homes in Waterloo Wellington. This indicator approximates one of three global measures of project impact described by MOHLTC in BSO funding agreements (Initial Indicator #2, rate of potentially avoidable ED visits for BSO target population residents of long-term care homes). Chart 6 Avoidable ED transfers are a function of countless factors, and statistically significant gains require system transformation starting with specific and local changes, adding up to better care quality, adding up to better outcomes at lower cost. In Waterloo Wellington, BSO is achieving the project s stated goals only 8 months after implementation. 29

30 Chapter 3 Qualitative 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. 3.1 Improvement Priorities * Please refer to table 3.1 on page Quality Improvement Impact of HQO coaching and leadership Moving into Q3, Health Quality Ontario (HQO) focused on three priorities to prepare the teams to shift their improvements to ongoing operations 1) building local improvement expertise and capacity; 2) planning for sustainability through kaizen events; and 3) using measurement to support sustainability and continuous improvement. As HQO s involvement in BSO came to completion at the end of December 2013, it was crucial that the LHIN BSO Improvement Facilitators felt competent and confident to provide ongoing support to their local teams. Building Local Improvement Capacity Health Quality Ontario (HQO) continued to develop Improvement Facilitators through monthly webinars focused on Applied Quality Improvement Science and Improvement Facilitator Team Consultation. In partnership with Residents First, an additional 242 individuals from Long Term Care and community BSO supports received 2-days of foundational quality improvement training, bringing the total to 406 new Improvement Facilitators trained across the province (shown in Figure 1). This additional QI capacity is a resource to be leveraged by the for BSO and future improvement initiatives. 30

31 Transitions Currently, 15% of all requests for Mobile Team service in the SE LHIN are for Transition Support. It is expected this share will rise as long-term care homes in the region learn more about the full complement of BSO services. Muriel, a long-term care resident in the SE LHIN, had fallen and was transferred to a local hospital emergency room. Diagnosed with a urinary tract infection and in a delirium, the family inferred to hospital staff that the LTC home was unable to provide safe care. The SE Mobile Response Team met with Muriel and her family in the hospital prior to discharge and, once Muriel returned to her LTC home, the Mobile Team worked alongside LTCH staff to help provide attention, reassurance and opportunities for Muriel to socialize and assist with daily living alongside LTCH staff. The family was involved with and included in Mobile Team activities, which assisted in a successful transition back to the LTCH by helping to build a level of trust with the LTCH staff. In Q3, the SE LHIN experienced their first transition between two regions; the Leeds Lanark and Grenville (LLG) & Hastings Prince Edward (HPE) Regions. By and large, transitions are not easy and more often than not they can be quite complicated affairs. When Charlie was transferred to LLG from HPE, members of the LLG team travelled to Bancroft and networked directly with him. HPE then sent two members of the team on a two day admission to support Charlie in his new LTCH. The collaboration between two region Mobile Teams and the enhanced integrated teams (outreach and PRC s) made for a challenging but successful transition for Charlie. Betty had an extended stay in a SE hospital and experienced many pressures including a surge status. With help from the Mobile Team, Betty was accepted at the LTCH of her choosing. This required unprecedented collaboration between staff from the Mobile Team, hospital, long-term care and the Psychogeriatric Outreach Team to assist in an early discharge from hospital. This team effort also included referrals to other partners, including Palliative Pain and Symptom Consultants. The long-term care home reported good support for the resident s transition. They felt their concerns were addressed quickly, including support with other challenging behaviours in the home before Betty arrived. In the North West, HQO developed and delivered a series of 5 weekly webinars to the North West team to begin to ground leaders in QI methodology. Participants had an opportunity to explore the Model for Improvement to begin to develop a toolkit with QI essentials: The aim statement to define the work ( what are we trying to accomplish? ); The tree diagram to visualize the ramps of change and how they interface; The problem statement and root cause analysis to understand the issue; PDSA cycles to develop, test and implement change ideas; and Change leadership to support the work (directing the logical riders, motivating the emotional elephants and shaping the path). This series was followed by 2 days Improvement Facilitation training and a kaizen event. In response to the unique geography of the North West, the session was delivered by coaches in 3 hubs (Thunder Bay, Fort Frances and Dryden). Using OTN, each hub contributed to curriculum delivery shared and experienced local exercises and activities. Figure 1: Number of participants in Improvement Facilitator training Activity measures are process measures that convey progress toward implementation of the change ideas that the teams believe will lead to an improvement. Planning for Sustainability through Kaizen Events As began planning to transition the work of BSO to ongoing operations, one area of focus for kaizen events was sustainability. Using the Sustainability Model from the NHS Institute for Improvement and Innovation as the framework, HQO worked with local Improvement Facilitators to codesign and co-deliver a session in Central East LHIN to reflect on their work to date; the process, staff and organizational factors that most impact on their ongoing sustainability; and action plans to enhance the likelihood that efforts will be sustained. 31

32 Likewise, sessions were hosted with North West, Waterloo Wellington, HNHB and Central LHIN teams. Each of these LHIN groups considered change leadership during their kaizen activities (where change management = efficiency = doing things the right way, contrasted to change leadership = effectiveness = doing the right things). By working through reflections on success factors, teams identified the supports they require from leaders, the supports they require from partners, and the supports others require from them. This reinforced the reciprocal accountabilities and the essential contributions of all team members. Using Measurement to Support Sustainability and Continuous Improvement In Q2, collaborative working groups identified consistent activity measures across leading practices. This array of measures reflected the BSO approach of local development to best meet local needs rather than requiring provincial solutions. Moving into Q3, data was reviewed with the intent of using measurement for learning within and between teams. Measures were associated with a single pillar to confirm representation of the entire BSO Framework. To be sustainable, BSO supports need to reflect the triple hat, providing direct services to the client, indirect services to the provider and building capacity for all in terms of service improvement. The activity measures positioned BSO to sustain the gains and directly support two process factors emphasized in the NHS Sustainability Guide, specifically: - Credibility of the evidence our ability to identify the benefits of the initiative and effectively communicate them to stakeholders - Effectiveness of the system to monitor progress continued measurement to prevent slippage and allow for further refinements Measurement is important to support sustainability of the changes that resulted in an 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. It has been Health Quality Ontario s pleasure to work with teams across the province throughout the past 16 months. The passion and commitment from individuals for this improvement work has been second to none. Communities in every LHIN across the province have truly brought the three BSO pillars to life by keeping individuals and their caregivers at the core of their improvement work and making changes to system coordination and management; integrated service delivery: inter-sectoral and interdisciplinary; and knowledgeable care team and capacity building. This unique combination of grass-roots social movement with strategic leadership and partnerships and pragmatic, on the ground quality improvement should be celebrated as to foundation for achievement of a large scale, system level change. Filter Robert, a 78-year-old with mild cognitive impairment and uncontrolled behaviours, was referred to the Toronto Central LHIN s Long-Term Care Behavioural Support Outreach Team by the BSO Psychogeriatric Resource Consultant. Due to an impairment, Robert was unable to filter his conversation and did not recognize when his actions were inappropriate. Following assessment, the Outreach Team implemented strategies designed to reduce Robert s behaviours including consistent use of the common phrase unacceptable language when abusive and/or insulting language was used. In addition, staff were provided with supplementary education and training on the topic of executive functioning impairments, thereby helping them to understand that Robert s behaviour was a result of the cognitive impairment. A pro-attention plan was also implemented to ensure Robert felt engaged and heard by staff. Furthermore, Robert s daughter was contacted to consider registering him for additional recreational programs. Upon follow-up, the Outreach Team received very positive feedback. The new strategies reduced the incidence of inappropriate and/or abusive behaviour, Robert feels more engaged and heard by staff, and staff have increased their capacity to support other clients with mild cognitive impairment. 32

33 THANK YOU! 33

34 Table 3.1 BSO Improvement Priorities Pillar LHIN Priority (items marked with * have an identified working group) ESC SW WW HNHB CW MH TC C CE SE CH NSM NE NW Primary Care Resource Toolkit (HNHB lead) * Mobile (Response) Teams (SE lead) LTC & Community * Mobile Team support of overnight adult day program relief future Behaviour Champion in LTCH (PRC role enhanced) PRCs to support Behavioural Support Units (MH lead) new/enhanced/ongoing * Use MHLHIN SBSU observe Enhanced crisis teams to be senior savvy (intensive Geriatric Service Facilitator & HCP) X CCAC role in the process Intensive Case Management role Supporting local networks enhance Dementia Care Network website Resident s First leverage work for Aim Statements & work plans Enhanced Access/One number to call/central Intake (NSM lead) * Integrated Community Lead (navigator); regional coordinator BSS coordinator Gateway book appointment and call back Access and Triage (part of central intake) Standardized Assessment Toolkit (NSM lead) * Common Processes Handoff Protocols Common Care Pathway Standardized Care Plans Physician engagement, order sets medical directives LTC Behavioural Assessment Tool (LTC for all residents that have behaviour) Behavioural Care Best Practices Community Care Algorithms agreements on processes leverage outreach teams (formalize informal agreements) Safe beds for transition Future Virtual ward (outreach) Education & training (PIECES, GPA, U-FIRST!) Consortium leverage existing PIECES Common Language Capacity Building LTC & Community Critical incident debriefing process Early Capacity/Caregiver Support/+/-First Link Transition Hospital to LTCH (include Tertiary) senior friendly hospital Consolidation of information resources CCAC Healthline Learning management system (on line availability) Pillar I: System coordination and management Pillar II: Integrated service delivery Pillar III: Knowledgeable care team and capacity building 34

35 Mealtime Charles, a resident at Pioneer Manor in the North East LHIN, was referred to the in-house BSO team after injuring another resident while portering him, in a wheelchair, to the dining table for mealtime. Charles portered other residents often and without being asked. The goal was to determine the root cause of Charles behaviour and to find a solution that would avoid altering his medications. After observing Charles, completing a personal history, and working through the P.I.E.C.E.S. framework, BSO staff tried several interventions including distraction, snacks, increased fluids. They also ensured staff were in his area 15 minutes prior to meals. However, his behaviour persisted so a BSO team meeting was called, pulling in house disciplines affected by the behaviour at the facility. Together as a team it was determined that his behaviour might be prompted by a desire to hasten the arrival of the meal itself by ensuring everyone made it to the table as quickly as possible. The solution was to try an earlier meal time, coupled with staff being present in his area earlier in order to easily redirect him if needed. Since the change in meal times there has been a significant decrease in Charles attempt to porter others and there have been no reported incidents of other residents being harmed. This change in behaviour was successfully achieved without altering Charles medications. This pleases his family, who can now continue to have meaningful conversations and other interactions with him. The process of collaboratively problem solving in order to find a positive outcome has helped to further unite the staff as a team. Perhaps most importantly, Charles and his fellow residents are now safer because of it BSO collaborative working groups Access and Flow In Q3, the Access and Flow Collaborative (formerly the Central Intake Collaborative Working Group) was heavily focused on visioning for the future. The group undertook an exercise in redefining the terms of reference and mandate, which resulted in an expanded scope for the group. Initially focused on central intake and enhanced access, the expanded scope includes a renewed focus on access and flow initiatives, including access, navigation, transitions and flow. As a result the group has updated the terms of reference, changed their name to the Access and Flow Collaborative and appointed two new co-chairs to lead the group into Following the renewed definition, the team quickly embarked on developing a work plan. Key goals have been articulated with activities associated with each goal. Key goals include; Implement access and flow initiatives in all, Troubleshoot together during implementation, Encourage common approaches and adoption of best practice and sustain and strengthen. With the renewed focus, goals and activities, the Access and Flow Collaborative is well positioned for 2013 and beyond to share lessons and agree on strategies that support coordinated delivery of behavioural services at the first point of contact for clients, caregivers and families. Mobile Team In Q3, the Mobile Team Collaborative was able to review, distill and assess the applicability of a set of metrics for quality and practice improvement that would be standardized across. Meeting on a bi-weekly basis, the Collaborative was able to refine metric definitions, inclusion and exclusion criteria, metric parameters (nominators / denominator) and reporting frequency. Members then 'practiced' working with potential metrics to collect, analyze and incorporate data into practice to determine metric usefulness. It was determined that 9 metrics would commonly be collected among all, while each LHIN would then determine the depth of analysis of each metric, and/or include other metrics that would be meaningful to their contextual realities. Additionally, an 'inventory' was taken among. The compliment of staff, professional designations, number, and scope of mobile teams in for most were documented. Some are still in the process of creating this inventory, and this continues to be a priority for the Collaborative. Behavioural Support Units In Q3, the Behavioural Support Unit Collaborative (BSU) reconvened following the approval of new behavioural units under the Specialized Unit provision of the Long-Term Care Homes Act, Combined with the approved Specialized Behavioural Unit operated at Sheridan Villa in Mississauga, there are approved behavioural units in the Toronto Central LHIN, and Central LHIN. The Champlain LHIN and North West LHIN are still awaiting ministry approval. 35

36 and their respective HSPs are now involved with the operation of BSUs and, as a result, the collaborative has been focused on sharing operational processes, and on using the group as a support network to discuss and resolve issues. This has led to discussion of potential for consistent processes and data collection. Topics discussed include development of a standardized client satisfaction tool, processes for tracking client discharged from the program, assessment of emergency department resources following discharge, resident eligibility and client flow. Discussion has also centered on the intake and discharge pathway for residents, to ensure processes support timely discharge of residents to appropriate locations following completion of their clinical goals. So too would this encourage the timely admission of others waiting for admission. Members of the collaborative are also exploring the potential of a standardized process for the development and completion of a third party program evaluation; a condition of the specialized unit stats approval from MOHLTC. Collaborative members completed a sustainability plan including goals for the collaborative within the next six, twelve and twenty four month periods. Identified was the need to continue providing resources and support to operational issues, sharing information, supporting the development of consistent evaluation processes, and supporting/contributing assistance to other considering the development of future BSUs. Representatives from other have expressed interest in joining the collaborative and, as a result, membership will be expanded to include other and their partner organizations as interest is expressed. Reunited In the Erie St. Clair LHIN, through use of intensive case management and coordination of expertise and services, BSO is working successfully to transition clients from hospital to community designations. Carla was admitted to hospital with a urinary tract infection, experiencing a psychosis relating to decompensation from a previous hospitalization one month prior and inability to recover fully from her past medical condition. Also, being a diabetic with uncontrolled blood sugars, Carla s family was unable to cope with her responsive behaviors, causing further decompensation. When rendering care, Carla s responsive behaviors continued to be problematic for both caregivers and hospital staff even with medication regimes in place. The BSO Specialized Case Manager at the Community Care Access Centre, in collaboration with hospital staff/physicians and through intensive case management of BSO, recommended an alternative approach including changes to dietary management & behavioral approaches used by staff, thereby impacting the rate at which her responsive behaviors settled. Recommendations were also made, by the BSO Specialized Case Manager, to enlist the expertise of a psychiatric consultation when it was evident that medication approaches used were not improving behavior. Further medication changes improved Carla s responsive behavioral management and her approach towards others. Within three months of referral to CCAC/BSO, Carla was discharged from hospital to a retirement home setting, reunited with her spouse and a normalized way of living served to enhance her overall interactions with family and friends. If the BSO Case Manager had not recommended a change to my mother s diet or the consultation of a psychiatrist, my mother would not be where she is today. - Carla s Daughter Of 23 Alternate Level of Care (ALC) BSO referrals, from October December 2012, 11 or 47.8% of those with responsive behaviors referred through the Community Care Access Centre (CCAC) Home First/Hospital Case Management process were discharged to LTC and/or community less than three months from time of admission to hospital. 36

37 BSO Capacity Building: The Right Tool at the Right Time 3.3 Capacity Building During Q3 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 Decision Making Framework The Road Ahead - During Q3 the BSO project finalized and released 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, will enable individuals and teams to make better decisions about how, why and with whom they plan their continued capacity BSO Capacity Building: The Right Tool at the Right Time - The BSO project also developed and released a visual resource which links the suite of capacity building tools available to support local decision making; Based Learning Tool, The Behavioural Education Training and Supports Inventory, and The Road Ahead. This decision tree is designed to help users make decisions about when to use each tool and how each tool can be integrated with and complement each other. Capacity Building Videos - During Q3 the project led the development of three capacity building video vignettes specific to the capacity building tools and linked directly to the decision tree (Capacity Building: The Right Tool at the Right Time). Each of these two-minute videos features a leader in the field talking about the application of one of the capacity building tools in their area, including: The Behavioural Education Training and Supports Inventory, The BSO Capacity Building Roadmap and The Road Ahead. Plans are currently in place to develop the final video for the Person and Practice Based Learning Tool in Q4. Education & Training Subgroup - The Education & Training Subgroup reconvened 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.). The group identified a plan to conduct stakeholder consultation in the New Year to inform an updated version of the Behavioural Education Training and Supports Inventory (BETSI) tool. These consultations will ensure that BETSI is applicable and accessible to multiple health sectors including but not limited to: long-term care, acute care, community care, primary care and caregivers. Capacity Building Videos For more information on BSO s Capacity Building Suite of tools and resources, please visit 37